As a matrix in the fabrication of provisional dental crowns and bridges .
Mini "custom tray" for impressions .
. Articulation of diagnostic molds
Articulation of the working cast against the opposing arch .
For fabrication of a maxillary bite guard, a maxillary anterior or posterior . bite plate or a maxillary anterior repositioning appliance
Direct fabrication of Maxillary sports guard in the mouth without models ●
Bite registration material either to be used directly or in combination with . three way trays (e.g. Triple Trays from Premier)
Reinforcement of three way trays .
For use in functional therapeutic cases as e.g. a Lucia Jig, anterior . repositioning splint etc.
Guiding matrix to help recreate anatomic form .

Device Description

The LuxaForm Plus is a detailed quick pre-impression matrix used in the fabrication of provisional crowns and bridges and can also be used as a bite registration material.

AI/ML Overview

This document is a 510(k) Summary for the LuxaForm Plus, a temporary crown and bridge resin material. The document does not describe acceptance criteria, a study proving the device meets acceptance criteria, or any of the detailed information requested for AI/ML device studies.

Instead, it focuses on demonstrating substantial equivalence to predicate devices based on similarities in design, chemical composition, and performance specifications. This is a common regulatory pathway for medical devices that are not AI/ML based.

Therefore, I cannot extract the requested information as it is not present in the provided text.

Here's a breakdown of why each point cannot be fulfilled based on the given information:

A table of acceptance criteria and the reported device performance: Not present. The document states "Substantial equivalence for this device was based on similarities in design, chemical composition and performance specifications as compared to predicate materials." It doesn't list specific acceptance criteria or performance metrics for LuxaForm Plus.
Sample sized used for the test set and the data provenance: No test set or data provenance is mentioned.
Number of experts used to establish the ground truth for the test set and the qualifications of those experts: Not applicable, as there's no test set or ground truth described in the AI/ML sense.
Adjudication method for the test set: Not applicable.
If a multi reader multi case (MRMC) comparative effectiveness study was done, If so, what was the effect size of how much human readers improve with AI vs without AI assistance: Not applicable. This document pertains to a physical dental material, not an AI/ML system assisting human readers.
If a standalone (i.e. algorithm only without human-in-the-loop performance) was done: Not applicable.
The type of ground truth used: Not applicable. The "ground truth" here is the chemical composition and performance of predicate devices, not clinical outcomes or expert labels.
The sample size for the training set: Not applicable, as no training set for an AI/ML model is mentioned.
How the ground truth for the training set was established: Not applicable.

In summary, the provided document is a 510(k) premarket notification for a physical dental material and does not contain the information requested about acceptance criteria and studies for an AI/ML device.

Summary

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JAN 1 6 2004

510(k) Summary

LuxaForm Plus Trade Name:

Sponsor: DMG USA, Inc. 414 South State Street Dover, DE 19901 Registration # not yet assigned Owner/Operator #9005969

Device Generic Name:

Temporary Crown and Bridge Resin Material

Classification:

According to Section 513 of the Federal Food, Drug, and Cosmetic Act, the device classification is Class II.

Predicate Devices:

The proposed LuxaForm Plus is substantially equivalent to the currently marketed DMG USA LuxaForm material, which was cleared for marketing bv FDA in K000951. In addition, the chemical composition of the LuxaForm Plus material includes materials found in both the Advantage Dental Products Temporary Crown Matrix Buttons as cleared in K900389 and the Heraeus Kulzer Paladur dental resin material, which was cleared in K915898.

Product Description:

The LuxaForm Plus is a detailed quick pre-impression matrix used in the fabrication of provisional crowns and bridges and can also be used as a bite registration material.

Indications for Use:

LuxaForm Plus is indicated for several uses:

As a matrix in the fabrication of provisional dental crowns and bridges .
Mini "custom tray" for impressions .
Articulation of diagnostic molds .
Articulation of the working cast against the opposing arch .
For fabrication of a maxillary bite guard, a maxillary anterior or posterior . bite plate or a maxillary anterior repositioning appliance
Direct fabrication of Maxillary sports guard in the mouth without models .

Confidential - This file contains proprietary, trade secret information which is the property of DMG USA and DMG Hamburg. This information may only be disclosed to or viewed by authorized (in writing) representatives of DMG, Delphi Medical Device Consulting, and the U.S. Food and Drug Administration.

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Bite registration material either to be used directly or in combination with . three way trays (e.g. Triple Trays from Premier)
Reinforcement of three way trays .
For use in functional therapeutic cases as e.g. a Lucia Jig, anterior . repositioning splint etc.
Guiding matrix to help recreate anatomic form .

Safety and Performance:

Substantial equivalence for this device was based on similarities in design, chemical composition and performance specifications as compared to predicate materials. The materials, performance specifications and essential design characteristics of the LuxaForm Plus are identical to those of the predicate devices.

Conclusion:

Based on the indications for use, technological characteristics, and comparison to predicate devices, the LuxaForm Plus has been shown to be safe and effective for its intended use.

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Image /page/2/Picture/1 description: The image shows the logo for the Department of Health & Human Services - USA. The logo is a circular seal with the words "DEPARTMENT OF HEALTH & HUMAN SERVICES - USA" written around the perimeter. Inside the circle is a stylized image of an eagle.

Food and Drug Administration 9200 Corporate Boulevard Rockville MD 20850

JAN 1 6 2004

DMG USA, Incorporated C/O Ms. Pamela Papineau, RAC Consultant Delphi Medical Device Consulting 5 Whitcomb Avenue Ayer, Massachusetts 01432

Re: K033227

Trade/Device Name: Luxaform Plus Regulation Number: 872-3770 Regulation Name: Temporary Crown and Bridge Resin Regulatory Class: II Product Code: EBG Dated: December 31, 2003 Received: January 7, 2004

Dear Ms. Papineau:

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.

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to such 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 - Ms. Papineau

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); 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.

This letter will allow you to begin marketing your device as described in your Section 510(k) premarket notification. The FDA finding of substantial equivalence of your device to a legally marketed predicate device results in a classification for your device and thus, permits your device to proceed to the market.

If you desire specific advice for your device on our labeling regulation (21 CFR Part 801), please contact the Office of Compliance at (301) 594-4613. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21CFR Part 807.97). You may obtain other general information on your responsibilitics under the Act from the Division of Small Manufacturers, International and Consumer Assistance at its toll-free number (800) 638-2041 or (301) 443-6597 or at its Internet address http://www.fda.gov/cdrh/dsma/dsmamain.html

Sincerely yours,

Chih-Lin, Ph.D.

Chiu Lin, Ph.D. Director Division of Anesthesiology, General Hospital, Infection Control and Dental Devices Office of Device Evaluation Center for Devices and Radiological Health

Enclosure

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Page

510(k) Number (if known):

Device Name: LuxaForm Plus____________________________________________________________________________________________________________________________________________________

Indications for Use:

LuxaForm Plus is indicated for the following uses:

As a matrix in the fabrication of provisional dental crowns and bridges .
Mini "custom tray" for impressions .
. Articulation of diagnostic molds
Articulation of the working cast against the opposing arch .
For fabrication of a maxillary bite guard, a maxillary anterior or posterior . bite plate or a maxillary anterior repositioning appliance
Direct fabrication of Maxillary sports guard in the mouth without models ●
Bite registration material either to be used directly or in combination with . three way trays (e.g. Triple Trays from Premier)
Reinforcement of three way trays .
For use in functional therapeutic cases as e.g. a Lucia Jig, anterior . repositioning splint etc.
Guiding matrix to help recreate anatomic form .

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

Concurrence of CDRH, Office of Device Evaluation (ODE)

(Division Sign-Off)
Division of Anesthesiology, General Hospita
Infection Control, Dental Devices
510(k) Number:

Prescription Use ✓ (Per 21 CFR 801.109)	OR Over-the -Counter Use
-----------------------------------------	--------------------------

(Division Sign-Off)	Susan Runser
Division of Anesthesiology, General Hospital,
Infection Control, Dental Devices
510(k) Number:	K033227

Regulation Number and Section

§ 872.3770 Temporary crown and bridge resin.

(a)
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.(b)
Classification. Class II.