MSN-006

K141562 · GC America, Inc. · EBG · Sep 5, 2014 · Dental

Device Facts

• Record ID: K141562
• Device Name: MSN-006
• Applicant: GC America, Inc.
• Product Code: EBG · Dental
• Decision Date: Sep 5, 2014
• Decision: SESE
• Submission Type: Traditional
• Regulation: 21 CFR 872.3770
• Device Class: Class 2

Intended Use

1. Fabrication of temporary crowns, bridges, inlays, onlays and veneers 2. Fabrication of long-term temporary restorations

Device Story

MSN-006 is a dual-cured, temporary crown and bridge resin system. It consists of two pastes (Paste A and B) supplied in a cartridge, which are combined using an automixing tip. The device is used by dental professionals in a clinical setting to fabricate temporary dental restorations, including crowns, bridges, inlays, onlays, and veneers, as well as long-term temporary restorations. The material is applied to the patient's prepared tooth structure to create the temporary restoration. The device benefits patients by providing a functional and aesthetic temporary solution during the period required for the fabrication of permanent dental prosthetics.

Clinical Evidence

Bench testing only. The device was evaluated against ISO 10477:2004 standards for polymer-based crown and bridge materials. Performance testing included measurements of flexural strength, water sorption, and solubility. Results indicate that the device meets or exceeds the requirements outlined in ISO 10477. Data were analyzed using basic statistics.

Technological Characteristics

Dual-cured, two-component resin/composite system. Supplied in cartridges for use with automixing tips. Complies with ISO 10477:2004 standards for polymer-based crown and bridge materials. Available in multiple shades (A1, A2, A3, A3.5, B1, B3, BW).

Indications for Use

Indicated for the fabrication of temporary crowns, bridges, inlays, onlays, veneers, and long-term temporary restorations in dental patients.

Regulatory Classification

Identification

A temporary crown and bridge resin is a device composed of a material, such as polymethylmethacrylate, intended to make a temporary prosthesis, such as a crown or bridge, for use until a permanent restoration is fabricated.

Predicate Devices

• Protemp Plus (K073296)
• Luxatemp Ultra (K101710)
• GC KALORE (K082434)
• G-Cem Automix (K073283)
• MFP-051 (K123631)

Submission Summary (Full Text)

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Image /page/0/Picture/1 description: The image shows the logo for the U.S. Department of Health & Human Services. The logo consists of a stylized caduceus, which is a symbol of medicine, with three figures in profile forming the staff. The text "DEPARTMENT OF HEALTH & HUMAN SERVICES - USA" is arranged in a circular fashion around the caduceus.

Food and Drug Administration 10903 New Hampshire Avenue Document Control Center - WO66-G609 Silver Spring, MD 20993-0002

GC America, Inc. Mark Heiss, DDS Director, Regulatory Affairs & Academic Affairs, and Professional Relations 3737 West 127th Street Alsip, IL 60803

Re: K141562 Trade/Device Name: MSN-006 Regulation Number: 21 CFR 872.3770 Regulation Name: Temporary Crown and Bridge Resin Regulatory Class: II Product Codes: EBG Dated: June 23, 2014 Received: June 25, 2014

Dear Dr. 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. 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.

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Page 2 - Dr. Heiss

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 801); medical device reporting (reporting of medical device-related adverse events) (21 CFR 803); good manufacturing practice requirements as set forth in the quality systems (QS) regulation (21 CFR Part 820); and if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050.

If you desire specific advice for your device on our labeling regulation (21 CFR Part 801), please contact the Division of Small Manufacturers, International and Consumer Assistance at its tollfree number [phone] or [phone] or at its Internet address http://www.fda.gov/MedicalDevices/ResourcesforYou/Industry/default.htm. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to http://www.fda.gov/MedicalDevices/Safety/ReportaProblem/default.htm for the CDRH's Office of Surveillance and Biometrics/Division of Postmarket Surveillance.

You may obtain other general information on your responsibilities under the Act from the Division of Small Manufacturers, International and Consumer Assistance at its toll-free number [phone] or [phone] or at its Internet address http://www.fda.gov/MedicalDevices/ResourcesforYou/Industry/default.htm.

Sincerely yours.

Mary S. Runner -S

Erin I. Keith, M.S. Director Division of Anesthesiology, General Hospital, Respiratory, Infection Control and Dental Devices Office of Device Evaluation Center for Devices and Radiological Health

Enclosure

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Section 4 - Indications for Use Statement

## Indications for Use

510(k) Number (if known): K141562

Device Name: MSN-006

Indications for Use:

- 1. Fabrication of temporary crowns, bridges, inlays, onlays and veneers
- 2. Fabrication of long-term temporary restorations

Prescription Use X (Part 21 CFR 801 Subpart D)

AND/OR

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

(PLEASE DO NOT WRITE BELOW THIS LINE-CONTINUE ON ANOTHER PAGE IF NEEDED)

Concurrence of CDRH, Office of Device Evaluation (ODE)

Page 4.1 of 4.1

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Image /page/3/Picture/1 description: The image shows the text "'GC'" in a stylized, green font. The letters are bold and slightly italicized, giving them a dynamic appearance. The single quotation marks are also in green and placed at the beginning and end of the text.

GC AMERICA INC.
3737 WEST 127TH STREET
ALSIP, ILLINOIS 60803
TEL [phone]
FAX [phone]

- Submitter Information: 1.
GC AMERICA INC.
3737 W. 127ª Street Alsip, IL 60803

| Contact Person: | Mark Heiss, D.D.S. |
|-----------------|--------------------|
| Phone: | [phone] |
| Fax: | [phone] |
| Date Prepared: | June 10, 2014 |

- Device Name: 2.

| Proprietary Name: | MSN-006 |
|------------------------|------------------------------------|
| Classification Name: | Crown and Bridge, Temporary, Resin |
| Device Classification: | Class II, 872.3770 |
| Product Code: | EBG |

- Predicate Devices: 3.

| Company | Device | 510(k) No. | Date Cleared |
|----------------------------|----------------|------------|--------------|
| 3M ESPE AG DENTAL PRODUCTS | Protemp Plus | K073296 | 01/09/2008 |
| DMG USA, INC | Luxatemp Ultra | K101710 | 09/28/2010 |
| GC America Inc. | GC KALORE | K082434 | 11/14/2008 |
| GC America Inc. | G-Cem Automix | K073283 | 02/20/2008 |
| GC America Inc. | MFP-051 | K123631 | 07/23/2013 |

- 4. Description of Device:
MSN-006 is a dual-cured, temporary crown and bridge resin. The components consists of Paste A and B, which are filled in a cartridge. Both pastes are automixed with a mixing tip.

- న్. Indications for Use:
- 1. Fabrication of temporary crowns, bridges, inlays, onlays and veneers 2. Fabrication of long-term temporary restorations
- Technological characteristics: 6.

The technical characteristics are similar (material formulation) but not the same as the predicate devices (Section 10). MSN-006 as compared to Protemp Plus and Luxatemp are two component systems based on resin/composite technology. Bench top testing indicates that even with different formulas, applicant device and predicate devices previously mentioned, meet specifications listed in ISO 10477 (Section 18).

- 7. Substantial equivalence:
The applicant device complies with all the requirements of ISO 10477: 2004 (Dentistry -Polymer-based crown and bridge materials).

The curing mechanism of the new and predicate devices is substantially equivalent in principle. Therefore, the new and predicate devices are the same/similar in function, and similar in composition and intended use. This supports that the compatibility and safety of the applicant device are substantially equivalent to the predicate devices.

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In summary, indications for previously mentioned predicate devices and applicant device are the same. Differences in bench top performance tests meet or exceed requirements as outlined in ISO 10477 (Section 18). Data was analyzed utilizing basic statics when comparing to ISO 10477 (Sections 12 and 18).

## Differences

The following differences may be noted between the predicate devices and MSN-006:

- · All products listed under "Performance Test Results" (Table 18) meet ISO 10477 and differences in Flexural Strength, Water Sorption and Solubility are noted.
- 8. Packaging

Refills:

1. EM Cartridge (L) 62.5g (50mL) (1), GC MIXING TIP II SSS (15) 2. EM Cartridge (S) 12.5g (10mL) (1), GC Automix Tip Regular (10) Mixing tip package: 1. GC MIXING TIP II SSS (60) 2. GC Automix Tip Regular (20) Dispenser package: 1. GC CARTRIDGE DISPENSER II (1) 2. GRADIA CORE DISPENSER GUN (1)

- 9. Shades A1, A2, A3, A3.5, B1, B3 and BW
## 10. Shelf Life Evaluation and Storage Conditions:

- Shelf Life 2 years ।
- Store in a cool and dark place. 4-25°C (39.2 77.0°F) ।