GC Fuji Triage EP

K193484 · GC America, Inc. · EMA · Jul 2, 2020 · Dental

Device Facts

• Record ID: K193484
• Device Name: GC Fuji Triage EP
• Applicant: GC America, Inc.
• Product Code: EMA · Dental
• Decision Date: Jul 2, 2020
• Decision: SESE
• Submission Type: Traditional
• Regulation: 21 CFR 872.3275
• Device Class: Class 2
• Attributes: Therapeutic

Intended Use

Pit & Fissure Sealant and Root Surface Sealant Hypersensitivity due to abrasion and early non-cavitated lesions Protection immature enamel Temporary filling including endodontic access

Device Story

Bioactive glass ionomer cement for temporary restoration; supplied as powder/liquid in capsules. Mixed via capsule mixer; applied to tooth cavities using capsule applier with proprietary elongation tip for deep/small cavities. Hardens via acid-base reaction between fluoro-alumino-silicate glass and polyacrylic acid; releases fluoride, aluminum, and strontium ions. Contains CPP-ACP additive to moderate cement strength without inhibiting setting reaction. Used by dental professionals in clinical settings. Provides temporary protection and desensitization; aids in managing early lesions and immature enamel.

Clinical Evidence

No clinical testing performed. Evidence consists of bench testing confirming compliance with ISO 9917-1:2007 (net setting time, compressive strength, acid erosion, optical properties, acid-soluble lead content, radiopacity) and biocompatibility assessment per ISO 10993-1:2018 (cytotoxicity, sensitivity, irritation).

Technological Characteristics

Bioactive glass ionomer cement; powder/liquid capsule system. Materials: Fluoro-alumino-silicate glass, polyacrylic acid, CPP-ACP. Hardening: Acid-base reaction forming hydrogel. Radiopaque. Complies with ISO 9917-1:2007. Storage: 4-25°C.

Indications for Use

Indicated for pit and fissure sealing, root surface sealing, treatment of hypersensitivity due to abrasion and early non-cavitated lesions, protection of immature enamel, and temporary filling including endodontic access.

Regulatory Classification

Identification

Zinc oxide-eugenol is a device composed of zinc oxide-eugenol intended to serve as a temporary tooth filling or as a base cement to affix a temporary tooth filling, to affix dental devices such as crowns or bridges, or to be applied to a tooth to protect the tooth pulp. Dental cement other than zinc oxide-eugenol is a device composed of various materials other than zinc oxide-eugenol intended to serve as a temporary tooth filling or as a base cement to affix a temporary tooth filling, to affix dental devices such as crowns or bridges, or to be applied to a tooth to protect the tooth pulp.

Predicate Devices

• GC Fuji Triage (K013198)

Reference Devices

• MI VARNISH (K102808)

Submission Summary (Full Text)

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July 2, 2020

GC America Inc. Mark Heiss Director, Regulatory Affairs 3737 W. 127th Street Alsip, Illinois 60780-3

Re: K193484

Trade/Device Name: GC Fuji Triage EP Regulation Number: 21 CFR 872.3275 Regulation Name: Dental Cement Regulatory Class: Class II Product Code: EMA Dated: June 2, 2020 Received: June 5, 2020

Dear Mark Heiss:

We have reviewed your Section 510(k) premarket notification of intent to market the device referenced above and have determined the device is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate commerce prior to May 28, 1976, the enactment date of the Medical Device Amendments, or to devices that have been reclassified in accordance with the provisions of the Federal Food, Drug, and Cosmetic Act (Act) that do not require approval of a premarket approval application (PMA). You may, therefore, market the device, subject to the general controls provisions of the Act. Although this letter refers to your product as a device, please be aware that some cleared products may instead be combination products. The 510(k) Premarket Notification Database located at https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm identifies combination product submissions. The general controls provisions of the Act include requirements for annual registration, listing of devices, good manufacturing practice, labeling, and prohibitions against misbranding and adulteration. Please note: CDRH does not evaluate information related to contract liability warranties. We remind you, however, that device labeling must be truthful and not misleading.

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to additional controls. Existing major regulations affecting your device can be found in the Code of Federal Regulations, Title 21, Parts 800 to 898. In addition, FDA may publish further announcements concerning your device in the Federal Register.

Please be advised that FDA's issuance of a substantial equivalence determination does not mean that FDA has made a determination that your device complies with other requirements of the Act or any Federal statutes and regulations administered by other Federal agencies. You must comply with all the Act's requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part

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801); medical device reporting of medical device-related adverse events) (21 CFR 803) for devices or postmarketing safety reporting (21 CFR 4, Subpart B) for combination products (see https://www.fda.gov/combination-products/guidance-regulatory-information/postmarketing-safety-reportingcombination-products); good manufacturing practice requirements as set forth in the quality systems (QS) regulation (21 CFR Part 820) for devices or current good manufacturing practices (21 CFR 4. Subpart A) for combination products; and, if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050.

Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21 CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to https://www.fda.gov/medical-device-safety/medical-device-reportingmdr-how-report-medical-device-problems.

For comprehensive regulatory information about medical devices and radiation-emitting products, including information about labeling regulations, please see Device Advice (https://www.fda.gov/medicaldevices/device-advice-comprehensive-regulatory-assistance) and CDRH Learn (https://www.fda.gov/training-and-continuing-education/cdrh-learn). Additionally, you may contact the Division of Industry and Consumer Education (DICE) to ask a question about a specific regulatory topic. See the DICE website (https://www.fda.gov/medical-device-advice-comprehensive-regulatoryassistance/contact-us-division-industry-and-consumer-education-dice) for more information or contact DICE by email ([e-mail]) or phone [phone] or 301-796-7100).

Sincerely,

for Srinivas "Nandu" Nandkumar, Ph.D. Director DHT1B: Division of Dental Devices OHT1: Office of Ophthalmic, Anesthesia, Respiratory, ENT and Dental Devices Office of Product Evaluation and Quality Center for Devices and Radiological Health

Enclosure

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| DEPARTMENT OF HEALTH AND HUMAN |
|--------------------------------|
| SERVICES |

Food and Drug Administration

# Indications for Use

Form Approved: OMB No. 0910-0120 Expiration Date: 06/30/2020 See PRA Statement below.

510(k) Number (if known)

Device Name GC Fuji Triage EP

Indications for Use (Describe)

- Pit & Fissure Sealant and Root Surface Sealant

- Hypersensitivity due to abrasion and early non-cavitated lesions
- Protection immature enamel
- Temporary filling including endodontic access

Type of Use (Select one or both, as applicable) 2 Prescription Use (Part 21 CFR 801 Subpart D)

_ Over-The-Counter Use (21 CFR 801 Subpart C)

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FORM FDA 3881 (7/17)

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# 510(k) Summary 1

| Submitter Information:<br>GC America Inc.<br>3737 W. 127th Street<br>Alsip, IL 60803 | |
|----------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------|
| Contact Person:<br>Phone:<br>Alternate Contact:<br>Phone:<br>Fax: | Mark Heiss, D.D.S.<br>[phone]<br>Lori Rietman<br>[phone]<br>[phone] |
| Date Prepared: | June 30, 2020 |
| 1. Device Name:<br>Proprietary Name:<br>Classification Name:<br>Device Classification: | GC Fuji Triage EP<br>Conventional Glass Ionomer Cement<br>Class II, 872.3275 |

EMA

- 2. Predicate Devices:
Product Code:

| Product | Applicant | 510(k) No. | Code No | Predicate | Decision Date |
|----------------|-----------------|------------|---------|-----------|---------------|
| GC Fuji Triage | GC America Inc. | K013198 | EMA | Primary | 10/29/2001 |
| MI VARNISH | GC America Inc. | K102808 | LBH | Reference | 12/22/2010 |

- 3. Description of Device:
GC Fuji Triage EP is a bioactive glass ionomer for temporary restorative material. The device consists of powder and liquid filled in a capsule and is mixed with a capsule mixer. Then, the mixture is applied directly to a cavity with a capsule applier. As an additional improvement, a proprietary elongation tip can be attached to the capsule nozzle which enables access to small or deep cavities. GC Fuji Triage EP contains CPP-ACP (casein phosphopeptide - amorphous calcium phosphate) in the formulation. CPP-ACP was added to moderate the strength of cement for its use and provide a source of Ca+ and HP04-2. CPP-ACP was chosen as the additive for regulating the strength because it does not interfere with the setting reaction of the material.

GC Fuji Triage EP Package: Capsule (Powder 0.30g/Liquid 0.15g) - QTY: 50

Shades available: Pink, White

Shelf Life and Storage Conditions:

- Shelf Life 2 years -
- -Recommended for optimal performance, store in a cool and dark place. 4-25℃ (39 - 77°F)
- 4. Performance Bench Tests:

It is confirmed that the device conforms to the required specifications of ISO 9917-1:2007.

### న్. Non-Clinical Performance Testing:

A biocompatibility assessment was completed according to ISO 10993-1:2018, Biological evaluation of medical devices - Part 1: Evaluation and testing within a risk management process.

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### Cytotoxicity (L929 MEM Elution Test)

Based on the criteria of the protocol of ISO 10993-5

### Sensitivity (Kligman Maximization Test)

Based on the criteria of the protocol of ISO 10993-10

### Irritation (Intracutaneous Injection Test)

Based on the criteria of the protocol of ISO 10993-10

GC Fuji Triage EP is a bioactive glass ionomer for temporary restorative and does come in contact with body tissues (tooth - enamel, dentin) for more than 30 days

In conclusion, biocompatibility of GC Fuji Triage EP is acceptable device from the biological evaluation result.

It is confirmed that the device conforms to the required specifications of ISO 9917-1: 2007 Dentistry -Water-based cements - Part 1: Powder/liquid acid-base cements and company standard is suitable for its intended use. Performance testing includes:

| | Property | Requirements |
|---|------------------------------|--------------------------------------------|
| 1 | Net setting time | 1.5 to 6 min |
| 2 | Compressive strength | More than 100 MPa |
| 3 | Acid erosion | Less than 0.17 mm |
| 4 | Optical properties (opacity) | 0.35 to 0.90 |
| 5 | Optical properties (color) | Match the nominated shade guide |
| 6 | Acid-soluble lead content | Less than 100mg/kg |
| 7 | Radiopacity | More than equivalent thickness of aluminum |

#### 6. Clinical Performance Testing

No clinical testing has been performed on this device.

#### 7. Comparison of Technology:

The hardening mechanism of GC Fuji Triage EP and GC Fuji Triage are substantially equivalent in principle. Thus, the applicant device and the predicate device are the same in function and similar in composition and intended use. This supports that the compatibility of the applicant device is substantially equivalent to the predicate devices.

The following differences may be noted between GC Fuji Triage EP and the predicate devices:

- GC Fuji Triage EP contains CPP-ACP (casein phosphopeptide amorphous calcium phosphate) in ● the formulation.
- GC Fuji Triage EP includes the elongation tip.
- The applicant device, Fuji Triage EP, is a glass ionomer cement while MI VARNISH is a topical fluoride varnish.

#### 8. Conclusion

The applicant device, GC Fuji Triage EP, is substantially equivalent in qualitative features to the comparative device, FUJI Triage.

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| | Applicant Device | Primary Device | Reference Device |
|-----------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| | GC Fuji Triage EP | FUJI Triage<br>K013198 | MI VARNISH<br>K102808 |
| Trade name | GC Fuji Triage EP | FUJI Triage<br>K013198 | MI VARNISH<br>K102808 |
| Manufacturer | GC Corporation | GC Corporation | GC Corporation |
| Product<br>category | Restorative glass ionomer cement | Restorative glass ionomer cement | Topical fluoride varnish |
| Powder/Liquid<br>ratio | Powder 0.30g/Liquid 0.15g | Powder 0.30g/Liquid 0.15g | Not applicable |
| Indications for<br>Use | 1. Pit & Fissure Sealant and Root Surface Sealant<br>2. Hypersensitivity due to abrasion and early non-<br>cavitated lesions<br>3. Protection immature enamel<br>4. Temporary filling including endodontic access | 1. Pit and fissure sealant.<br>2. Treatment of early non-cavitated lesions; such<br>as tooth brush abrasion and root surface<br>sensitivity<br>3. Intermediate restorative material<br>4. Temporary filling of endodontic access. | Treatment of hypersensitive teeth. |
| Product<br>description | The Device consists of powder and liquid and filled in a<br>capsule. The mixed cement sets by acid-base reaction of<br>fluoro-alumino-silicate glass and polyacrylic acid. | The device consists of powder and liquid and<br>filled in a capsule. The mixed cement sets by<br>acid-base reaction of fluoro-alumino-silicate<br>glass and polyacrylic acid. | The device is a 5% sodium fluoride<br>varnish that a desensitizing action<br>when applied to tooth surfaces. The<br>application leaves a film of varnish on<br>tooth surfaces. |
| Technological<br>Characteristics<br>and Mode of<br>action | GC Fuji Triage EP contains CPP-ACP (casein<br>phosphopeptide - amorphous calcium phosphate).<br>CPP-ACP was added to moderate the strength of<br>cement for the use as more temporary or provisional<br>restoration material. CPP-ACP was chosen as the<br>additive for regulating the strength because it does not<br>inhibit the setting reaction of the material while can tone<br>down the physical strength.<br>Aluminum ion, Strontium ion and Fluoride ion are<br>released from Fluoro-alumino-silicate glass due to this<br>reaction. Of these ions, Aluminum ion and Strontium ion<br>crosslink the polyacrylic acid and form hydrogel.<br>Fluoride ion doesn't react, it remains inside hydrogel as<br>ion. This material set by the above reaction. The set<br>material contains fluoride ion inside as free ion. These<br>ions can be gradually release from the setting material<br>in very small amounts with time. | GC Fuji Triage Capsule is radiopaque glass<br>ionomer protection and temporary restorative<br>material in capsules consisting of powder and<br>liquid. The powder is Fluoro-alumino-silicate<br>glass and liquid is Polyacrylic acid solution.<br>They are mixed with an electrical capsule mixer<br>and applied directly to a cavity with a capsule<br>applier. Aluminum ion, Strontium ion and<br>Fluoride ion are released from Fluoro-alumino-<br>silicate glass due to this reaction. Of these ions,<br>Aluminum ion and Strontium ion crosslink the<br>polyacrylic acid and form hydrogel. Fluoride ion<br>doesn't react, it remains inside hydrogel as ion.<br>This material set by the above reaction. The set<br>material contains fluoride ion inside as free ion.<br>These ions can be gradually release from the<br>setting material in very small amounts with time. | MI Varnish is a paste formula<br>delivered in unit dose package. The<br>laminating film lid is peeled off and<br>the paste is applied on the tooth<br>surface with a disposable brush. The<br>device is a 5% sodium fluoride<br>varnish and also contains CPP-ACP<br>(casein phosphopeptide -<br>amorphous calcium phosphate) in<br>the formula. When the device is<br>applied on the tooth surface, a thin<br>film of varnish is left on the tooth<br>surface by evaporation of ethanol on<br>tooth. The film is composed by<br>polyvinyl acetate as film former and<br>hydrogenated rosin as adhesives.<br>The film works for desensitizing of<br>the tooth surface. |