HU-FRIEDY EXPRO
Received Mar 16, 2012
Report 1416605-2012-00001 · MDR key 2496662
Device
Product problems
- Material Fragmentation
Patient
Not reported
- Device Embedded In Tissue or Plaque
Narrative
Description of Event or Problem
DURING THE COURSE OF A ROOT CANAL PROCEDURE, A DOCTOR WAS USING A HU-FRIEDY PROBE TO MEASURE A CANAL ABSCESS. THE FOLLOWING WEEK, THE PT RETURNED TO THE DOCTOR FOR A F/U AND THE DOCTOR NOTICED THAT A SMALL PIECE OF THE TIP OF THE PROBE WAS EMBEDDED IN THE PT'S TISSUE. THE DOCTOR INFORMED THE PT AND INDICATED THAT HE WOULD NEED TO MAKE A SMALL SURGICAL INCISION TO REMOVE THE EMBEDDED TIP. THE DOCTOR PROCEEDED TO REMOVE THE TIP AND THE SURGICAL SITE HEALED W/O ANY FURTHER COMPLICATIONS.
Additional Manufacturer Narrative
THE RETURNED INSTRUMENT IS BROKEN NEAR THE 3 MM MARKING. FRACTURE SURFACE SHOWS NO SIGNS OF CORROSION. BOTH WORKING END S OF THE RETURNED INSTRUMENT ARE BENT AND DO NOT MATCH HU-FRIEDY MASTER SAMPLE IN SHAPE. RETURNED EXPO WAS VISUALLY INSPECTED UNDER MAGNIFICATION (20X) AND THE REMAINING SECTION OF THE PROBE END AND THE EXPLORER WORKING END WERE FOUND TO HAVE DEEP NICKS AND SCRATCHES. THE DEEP NICKS AND SCRATCHES ARE INDICATION OF THE TIPS GETTING CAUGHT IN THE HOLES OF AN ULTRASONIC CLEANER BASKET/TRAY OVER TIME. THIS CAUSES TIPS TO BEND AND IF WORKING END ARE RE-SHAPED, THIS TYPE OF MOVEMENT CAN LEAD TO LOW CYCLE FATIGUE WHEREBY A FORCE HIGHER THAN MATERIAL CAPABILITY CAN LEAD TO BREAKAGE OF THE TIP. ADDITIONALLY, THESE TYPES OF INSTRUMENTS (XPC44757C) HAVE A NORMAL LIFE EXPECTANCY OF UP TO 4 YRS. THE RETURNED INSTRUMENT WAS MANUFACTURED OVER 5 YRS AGO (AUG. 2006).
Remedial action
- Other