MAUDE Adverse Event Report: RANIR LLC READY TO WEAR NITE PROTECTOR; BRUXISM MOUTH GUARD

Device Problem Material Integrity Problem (2978)

Patient Problem No Consequences Or Impact To Patient (2199)

Event Date 01/20/2015

Event Type  No Answer Provided  

Event Description

A piece broke off the mouth guard.

• Brand Name: READY TO WEAR NITE PROTECTOR
• Type of Device: BRUXISM MOUTH GUARD
• Manufacturer (Section D): RANIR LLC; 4701 east paris ave se; grand rapids MI 49512 535
• Manufacturer (Section G): RANIR LLC; 4701 east paris ave se; grand rapids MI 49512 535
• Manufacturer Contact: elsa baker ; 4701 east paris se; grand rapids, MI 49512-5353 ; 6166988880
• MDR Report Key: 4523709
• MDR Text Key: 5358939
• Report Number: 1825660-2015-00010
• Device Sequence Number: 1
• Product Code: OBR
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K112879
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Invalid Data
• Reporter Occupation: Device Unattended
• Remedial Action: Replace
• Type of Report: Initial
• Report Date: 02/18/2015

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 02/18/2015
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Other
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Event Location: Home
• Date Manufacturer Received: 01/20/2015
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Unknown
• Patient Sequence Number: 1