BEUDAMED
    FDA Adverse Event Injury Summary report: N

    SMILEDIRECTCLUB ALIGNER SYSTEM

    MDR report key: 13118543 · Received December 30, 2021

    Report

    Report Number
    3014658399-2021-01781
    Event Type
    Injury
    Date Received
    December 30, 2021
    Date of Event
    July 13, 2021
    Report Date
    December 30, 2021
    Manufacturer
    ACCESS DENTAL LAB
    Product Code
    NXC
    PMA / PMN Number
    K191990
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    UK
    Reporter Occupation
    003

    Narratives

    Additional Manufacturer Narrative · 0

    BASED ON THE INFORMATION PROVIDED BY THE PATIENT, THERE IS NO CONCLUSIVE EVIDENCE THAT SUPPORTS OR OPPOSES THE FACT THAT THE ALIGNERS CAUSED, CONTRIBUTED, OR WOULD LIKELY CAUSE OR CONTRIBUTE TO THE REPORTED EVENT. THIS EVENT IS BEING FILED AS AN MDR SINCE THE PATIENT REPORTED SYMPTOMS OR PHYSIOLOGICAL CONDITIONS RELATED TO TOOTH BREAKAGE WHICH THE CUSTOMER STATED RESULTED IN EXTRACTION OF THE TOOTH. AS PER CAPA # (B)(4) THIS EVENT IS RETROSPECTIVELY BEING REPORTED AND THEREFORE WAS NOT REPORTED WITHIN THE REQUIRED 30-DAYS.

    Description of Event or Problem · 0

    THE CUSTOMER REPORTED A CHIPPED TOOTH AND A EXTRACTION OF A TOOTH WHILE WEARING THE ALIGNERS, THE CUSTOMER WAS NOT ABLE TO PROVIDE THE IMPACTED TOOTH NUMBER. IT IS UNKNOWN IF MEDICAL INTERVENTION WAS REQUIRED. IT IS UNKNOWN IF ALIGNER TREATMENT WAS DISCONTINUED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    2017979 SMILEDIRECTCLUB ALIGNER SYSTEM SEQUENTIAL ALIGNER NXC ACCESS DENTAL LAB N/A N/A

    Patients

    Seq Age Sex Outcome Treatment
    1 40 YR Unknown Other