FDA Adverse Event Injury Summary report: N

YOMI GUIDED DENTAL IMPLANT ROBOT

MDR report key: 18783685 · Received February 23, 2024

Report

Report Number
MW5151999
Event Type
Injury
Date Received
February 23, 2024
Date of Event
June 6, 2023
Report Date
February 21, 2024
Manufacturer
NEOCIS INC
Product Code
QRY
Adverse Event
Yes
Product Problem
Yes
Report Source
Voluntary report
Reporter Location
SC, US
Reporter Occupation
DENTIST
Health Professional
Yes

Narratives

Description of Event or Problem · 0

I WAS USING THE YOMI ROBOT TO PLACE DENTAL IMPLANTS ON A SEDATED PATIENT UNDER THE SUPERVISION OF THE COMPANY TRAINOR. THE ROBOT ARM WAS ATTACHED TO THE PATIENT'S ANTERIOR MAXILLA WITH FOUR 3/4-INCH STRYKER SURGICAL SCREWS. THE SURGERY WAS GOING AS PLANNED WHEN THE ROBOT VERY QUICKLY AND VIOLENTLY LIFTED MY PATIENT'S HEAD OFF THE REST AND SLAMMED IT DOWN AND PINNED IT AGAINST THE CHAIR EIGHT INCHES TO THE LEFT OF THE ORIGINAL POSITION. I WAS UNABLE TO MOVE THE ARM OR THE PATIENT'S HEAD. THE TRAINOR WAS PANICKED AND DID NOT HAVE AN IMMEDIATE SOLUTION. AFTER A FEW MINUTES SHE WAS ABLE TO DISABLE THE ROBOT AND FREE THE PATIENT'S HEAD. THE SURGICAL FASTENING SCREWS WERE LOOSENED AND BENT AT A 30-DEGREE ANGLE. THANK GOODNESS THE PATIENT WAS A ROBUST 200LB HEALTHY 52-YEAR-OLD MAN AND WAS NOT SERIOUSLY INJURED. IF IT WOULD HAVE BEEN A MORE FRAIL PATIENT I BELIEVE THIS OCULD HAVE LED TO SERIOUS INJURY OR DEATH. WE ARE ABLE TO REPRODUCE THE ACTION THE ROBOT EXHIBITED AND THE COMPANY IS AWARE AND HAS NOT BEEN ABLE TO PROVIDE A SOLUTION. THERE ARE CLOSE TO 200 OF THESE FDA APPROVED ROBOTS IN SERVICE AND I AM CERTAIN UNLESS THE PROBLEM IS RESOLVED THERE WILL BE A TRAGIC EVENT. IN ADDITION, MY ANESTHESIOLOGIST BELIEVES THAT WITH THE ROBOT ARM ATTACHED IT WOULD BE IMPOSSIBLE TO ACHIEVE POSITIVE PRESSURE VENTILATION IN AN AIRWAY EMERGENCY.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
116888 YOMI GUIDED DENTAL IMPLANT ROBOT DENTAL NAVIGATION SYSTEM QRY NEOCIS INC

Patients

Seq Age Sex Outcome Treatment
1 52 YR Male Required Intervention FOUR STRYKER SURGICAL SCREWS.