BEUDAMED
    FDA Adverse Event Injury Summary report: N

    CMF VISIONARE

    MDR report key: 21037149 · Received December 30, 2024

    Report

    Report Number
    3011196443-2024-00002
    Event Type
    Injury
    Date Received
    December 30, 2024
    Date of Event
    November 18, 2024
    Report Date
    December 30, 2024
    Manufacturer
    VISIONARE LLC
    Product Code
    JEY
    UDI-DI
    00810004511170
    PMA / PMN Number
    K180204
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    FL, US
    Reporter Occupation
    003

    Narratives

    Additional Manufacturer Narrative · 0

    WE FULLY RESPECT THE SURGEON'S DECISION TO USE A PRODUCT THAT IS NOT IDEAL FOR THE INTENDED TECHNIQUE, SO REGARDING THE "PLATE BREAKAGE", WE SUGGEST MONITORING THE EVOLUTION OF EACH PATIENT'S CLINICAL CONDITION AND IF NECESSARY, PROVIDE FOR THE REPLACEMENT OF BROKEN PLATE BY THE PLATE INDICATED FOR ORTHOGNATHIC SURGERY. WE REMAIN ENTIRELY AT THE DISPOSAL OF THE AUTHORITIES, IF THERE ANY ADDITIONAL QUESTIONS.

    Description of Event or Problem · 0

    ACCORDING TO THE HEALTH PROFESSIONAL DESCRIPTION: "DURING THE YEAR 2024, (B)(6) COMPANY STARTED THE EXCLUSIVE SUPPLY OF ORTHOSES, PROSTHESES AND SPECIAL FIXATION MATERIALS FOR THE SPECIALTY OF BUCO-MAXILO-FACIAL, WITH THE SUPPLY OF VISIONARE BRAND FIXING PLATES. DURING THIS PERIOD, I NOTICED A SIGNIFICANT INCREASE IN PATIENTS WHO EVOLVED TO FRACTURE OF THE PLATES INSTALLED IN THE JAW, WITHOUT APPARENT REASON. THE FRACTURE OF THE FIXATION PLATES CAN INTERFERE WITH THE HEALING OF THE JAW, CAUSING BAD OCCLUSIONS, PSEUDOARTHROSIS, OSTEOMYELITIS, AMONG OTHER PROBLEMS, WHICH WILL OFTEN BE SOLVED WITH NEW SURGICAL INTERVENTIONS." COMPLAINT OCCURRED IN BRAZILIAN MARKET. THIS CONTENT WAS TRANSLATED FROM PORTUGUESE TO ENGLISH BY VISIONARE. THE ORIGINAL COMPLAINT REPORTED 4 PLATES BROKEN, HOWEVER, DATA FROM ONLY 3 PATIENTS WERE SHARED. THIS OCCURRENCE GENERATED THE NEED TO NOTIFY ADVERSE EVENTS TO ANVISA THROUGH NOTIFICATION NO. (B)(4). THIS EVENT WILL BE ACCOUNTED FOR AND MONITORED THROUGH POST-MARKET SURVEILLANCE ACTIVITIES. IF ADDITIONAL INFORMATION BECOMES AVAILABLE, THE INVESTIGATION WILL BE UPDATED AS APPLICABLE. AS THERE ARE OCCURRENCES WITH 3 DIFFERENT PATIENTS, THE COMPANY WILL MAKE 3 ADVERSE EVENTS NOTIFICATIONS AT FDA. INVESTIGATION: IT WAS EVIDENCED THAT THE IMPLANT 1.904.006 WERE APPLIED IN THE ORTHOGNATHIC SURGICAL TECHNIQUE, WHICH IS NOT RECOMMENDED. VISIONARE HAS A SPECIFIC LINE OF PRODUCTS FOR SUCH APPLICATION, SO WE RECOMMENDED THAT FOR ORTHOGNATHIC SURGERY PROCEDURE, THE SPECIFIC IMPLANTS OF VISIONARE ORTHOGNATHIC LINE BE USED. THE RHP (HISTORICAL PRODUCTION RECORD) OF THE BATCH OF THE OCCURRENCES' OBJECT WAS ALSO EVALUATED AND NO DIVERGENCES WERE OBSERVED IN THE MODES OF FAILURES THAT COULD LEAD TO THE REPORTED OCCURRENCES, SHOWING THAT THE PRODUCTS MET THE LEVEL OF SAFETY AND EFFECTIVENESS ESTABLISHED BY THE PROJECT. BASED ON THE ABOVE-MENTIONED ASSESSMENT, THIS COMPLAINT BEING CATEGORIZED AS UNFOUNDED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    2116970 CMF VISIONARE 1.904.006 - 4 HOLE LONG STRAIGHT MINIPLATE, T 1.0MM JEY VISIONARE LLC 1.904.006 2808409 00810004511170

    Patients

    Seq Age Sex Outcome Treatment
    1 39 YR Female Required Intervention