MAUDE Adverse Event Report: ULAB SYSTEMS ULAB SYSTEMS DENTAL ALIGNER; FG0094, ULAB SYSTEMS ALIGNER KIT

Model Number	FG0094
Medical Device Problem Code	Patient Device Interaction Problem (4001)
Health Effect - Clinical Code	Hypersensitivity/Allergic reaction (1907)
Date of Event	07/19/2025
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Who: the doctor contacted ulab regarding a possible allergic reaction.What: the patient is experiencing irritation and is currently under medical care.When: on (b)(6) 2025.Where: at the doctor's office while treating the patient.Why: no rma no manufacturing defects.Inspected at qa03 by #: (b)(4) on 1/29/2025 per discussion in the complaint meeting on (b)(6) 2025, requesting more information from the doctor regarding known allergies, did the symptoms stop once they discontinued wearing the aligners, what were the results of the medical attention? conclusion: this complaint will close as undetermined.This reaction may be due to other external factors/common allergens that were introduced coincidentally at same time as the placement of the aligners, such as pollens, dustmites, pet allergens, biologic products, insect venoms.The cause of the possible allergic reaction is undetermined.The doctor provided the symptoms the patient displayed but no further information.The product was not returned.Ulab systems reported this minor allergic reaction as an emdr through our webtrader production account, on (b)(6) 2025.
Event or Problem Description
Who: the doctor contacted ulab regarding a possible allergic reaction.What: the patient is experiencing irritation and is currently under medical care.When: on (b)(6) 2025.Where: at the doctor's office while treating the patient.Why: no rma no manufacturing defects.Inspected at qa03 by #: (b)(4) on 1/29/2025 per discussion in the complaint meeting on (b)(6) 2025, requesting more information from the doctor regarding known allergies, did the symptoms stop once they discontinued wearing the aligners, what were the results of the medical attention? conclusion: this complaint will close as undetermined.This reaction may be due to other external factors/common allergens that were introduced coincidentally at same time as the placement of the aligners, such as pollens, dustmites, pet allergens, biologic products, insect venoms.The cause of the possible allergic reaction is undetermined.The doctor provided the symptoms the patient displayed but no further information.The product was not returned.Ulab systems reported this minor allergic reaction as an emdr through our webtrader production account, on (b)(6) 2025.

• Brand Name: ULAB SYSTEMS DENTAL ALIGNER
• Common Device Name: FG0094, ULAB SYSTEMS ALIGNER KIT
• Manufacturer (Section D): ULAB SYSTEMS; 7005 appling farms parkway; memphis TN 38133
• Manufacturer (Section G): ULAB SYSTEMS; 7005 appling farms parkway; memphis TN 38133
• Manufacturer Contact: aswin srinivasan ; 7005 appling farms parkway; memphis, TN 38133 ; 8669008522
• MDR Report Key: 22647703
• Report Number: 3017155477-2025-00018
• Device Sequence Number: 8762495
• Product Code: NXC
• UDI-Device Identifier: 00860002380094
• UDI-Public: 00860002380094
• Combination Product (Y/N): Y
• Initial Reporter State: CA
• Initial Reporter Country: US
• PMA/510(K) Number: K192596
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional
• Initial Reporter Occupation: Dentist
• Remedial Action: Other
• Type of Report: Initial
• Report Date (Section B): 07/29/2025

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Health Professional
• Device Model Number: FG0094
• Device Catalogue Number: N/A
• Device Lot Number: KKN15
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 07/09/2025
• Initial Report FDA Received Date: 07/29/2025
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 01/29/2025
• Is the Device Labeled for Single Use? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: FG0094, ULAB SYSTEMS USMILE ALIGNER KIT.
• Outcome Attributed to Adverse Event: Other
• Patient Sex: Male