MAUDE Adverse Event Report: NAKANISHI INC. NSK; HANDPIECE, ROTARY BONE CUTTING

Model Number SGA-ES

Device Problem Overheating of Device (1437)

Patient Problem Burn(s) (1757)

Event Date 09/30/2022

Event Type  Injury  

Manufacturer Narrative

The dentist refused to provide information about the patient's weight, ethnicity, and race.Upon receiving the device involved in the mdr event, nakanishi conducted a failure analysis of the returned device, which included measuring the operating temperature of the device [report no.(b)(4)].These activities are described in more detail below.Methodology used: a) nakanishi examined the device history record and the repair history for the subject sga-es device [(b)(4)].There were no problems observed during manufacturing or testing noted in the dhr.The repair history showed 4 service records since the device was shipped.The repair details are as follows: - (b)(6) 2019: the bearings, bur pusher retainer, slider, bur pusher pipe, and spacers were replaced.- (b)(6) 2019: the bearings, bur pusher retainer, and bur pusher pipe were replaced.- (b)(6) 2020: the bearings and bur pusher retainer were replaced.- (b)(6) 2020: same as above.With respect to the repairs in the above list, the service records indicate that nakanishi performed all of the necessary operation checks and confirmed that all of the criteria were met.B) nakanishi conducted temperature testing of the returned device in the following manner: b.1) temperature sensors were attached to the exterior of the device at various test points.This included the point most proximal to the patient (testing point (1)) and points further toward the distal end of the device (testing points (2) through (4)).The test setup was prepared to take temperature measurements at all points simultaneously, including a reference measurement at ambient room temperature.B.2) nakanishi attached a thermocouple (sensor to measure temperature) to each of the testing points.Nakanishi rotated the device's motor at 40,000min-1, which is the maximum rpm for the motor that drives the handpiece (40,000min-1 for the handpiece), without water spray, and measured the exothermic response.B.3) nakanishi measured the temperature rise of the returned handpiece set at 40,000min-1 (motor revolution 40,000min-1).Nakanishi observed an abnormal temperature rise at the test points (1) and (2) 100 seconds into the test.Temperature measurements about 5 minutes after the start of the test were as follows: - test point (1): 81.5 degrees c, - test point (2): 72.7 degrees c, - test point (3): 44.8 degrees c, - test point (4): 40.4 degrees c.Identification of the specific failure mode(s) and/or mechanism(s) of the associated device components was conducted as follows: a) nakanishi disassembled the handpiece and performed a visual inspection of the internal parts.Nakanishi observed the following: - the bearing retainer in the ball bearing was broken.- the internal parts, such as ball bearing, spindle and dog clutch were soiled and discolored.B) nakanishi took photographs of all the disassembled parts and kept them in the investigation report no.(b)(4).Conclusions reached based on the investigation and analysis results: a) nakanishi determined that the cause of the handpiece overheating was abnormal resistance during rotation due to the broken bearing.Nakanishi considers the possibility from many years of experience that the cause of the broken bearing was the ingress of undesirable materials into the bearing, leading to abrasion.B) a lack of maintenance caused the accumulation of debris on the internal parts, which caused debris ingress into the bearing during rotation.This contributed to the handpiece overheating.C) in order to prevent a recurrence of the handpiece overheating, nakanishi took the following actions: c.1) nakanishi reviewed the operation manual and reconfirmed the clarity and understandability of the instructions.C.2) nakanishi reported the above evaluation results to the dentist and reminded the dentist of the importance of maintenance as instructed in the operation manual.

Event Description

On (b)(6) 2022, nakanishi received a phone call from a dealer about an nsk handpiece overheating.The details nakanishi obtained are as follows: - the event occurred on (b)(6) 2022.- the dentist was extracting a wisdom tooth of a patient's lower jaw using the sga-es handpiece (serial no.(b)(4)).- the patient was under general anesthesia.- during the procedure, the handpiece overheated, and the patient received a whitish burn injury to their right buccal mucosa approximately 20mm in diameter.- the dentist applied vaseline ointment to the burn injury of the patient.

• Brand Name: NSK
• Type of Device: HANDPIECE, ROTARY BONE CUTTING
• Manufacturer (Section D): NAKANISHI INC.; 700 shimohinata; kanuma-shi, tochigi-ken 322-8 666; JA 322-8666
• Manufacturer (Section G): NAKANISHI INC.; 700 shimohinata; kanuma-shi, tochigi-ken 322-8 666; JA 322-8666
• Manufacturer Contact: sean kaufman ; 1800 global parkway; hoffman estates, IL 60192 ; 2245128921
• MDR Report Key: 15664391
• MDR Text Key: 302324456
• Report Number: 9611253-2022-00078
• Device Sequence Number: 1
• Product Code: KMW
• Combination Product (y/n): N
• Reporter Country Code: JA
• PMA/PMN Number: K171155
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Other,Foreign
• Reporter Occupation: Non-Healthcare Professional
• Remedial Action: Recall
• Type of Report: Initial
• Report Date: 10/25/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 10/24/2022
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: SGA-ES
• Device Catalogue Number: H263
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 10/17/2022
• Date Manufacturer Received: 10/07/2022
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 02/01/2018
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Reuse
• Removal/Correction Number: 9611253-060818-001-R
• Patient Sequence Number: 1
• Patient Outcome(s): Other
• Patient Age: 27 YR
• Patient Sex: Male