K Number
K191448
Device Name
Barrier Sleeves
Date Cleared
2019-10-08

(130 days)

Product Code
Regulation Number
878.4370
Panel
Dental
Reference & Predicate Devices
Predicate For
AI/MLSaMDIVD (In Vitro Diagnostic)TherapeuticDiagnosticis PCCP AuthorizedThirdpartyExpeditedreview
Intended Use

Barrier Sleeves are intended to serve as a disposable barrier for dental instruments and equipment. This device is non-sterile and intended for single patient use only.

Device Description

Barrier Sleeves are made of polyethylene film and are used as accessories to dental instruments and equipment used during dental procedures. These disposable barrier sleeves are offered in various shapes and sizes to fit over and cover the intended dental instruments and equipment. The disposable Barrier Sleeves slip over the ends of the respective devices, allowing for the attachment of the devices used during dental procedures. Barrier Sleeves act as a physical barrier, augmenting existing infection control techniques, and facilitate clean-up.

AI/ML Overview

The provided text describes the 510(k) premarket notification for "Barrier Sleeves" by Ivoclar Vivadent, AG. This document focuses on demonstrating substantial equivalence to a predicate device, rather than proving a new device's independent efficacy through a "study that proves the device meets the acceptance criteria" in the context of, for example, an AI/ML medical device.

The "acceptance criteria" here are based on the similarity to the predicate device and meeting established performance standards for surgical drapes/barrier materials. The study described is a series of non-clinical bench tests and biocompatibility assessments.

Here's how to structure the information based on your request, with the understanding that this is not an AI/ML device study, but rather a traditional medical device submission for substantial equivalence:

Device: Barrier Sleeves (K191448)

Intended Use: "Barrier Sleeves are intended to serve as a disposable barrier for dental instruments and equipment. This device is non-sterile and intended for single patient use only."

The claim of substantial equivalence is supported by demonstrating that the Barrier Sleeves have the same intended use, fundamental technology, working principle, material composition, and comparable performance properties to the predicate device (Disposable Barrier Sleeves and Covers, K160232) manufactured by the same supplier.


1. Table of Acceptance Criteria and Reported Device Performance

For this type of device, "acceptance criteria" are implied by demonstrating equivalence to a legally marketed predicate device and meeting relevant industry standards for barrier materials. The study is a series of physical and biological tests.

CategoryAcceptance Criteria (Implied by Predicate & Standards)Reported Device Performance (Barrier Sleeves)
Indications for UseSame as predicate (disposable barrier for dental instruments and equipment)Same as predicate
Working PrincipleSame as predicate (polyethylene film slipping over devices as physical barrier)Same as predicate
Material CompositionSame as predicate (Low density polyethylene film from same supplier)Identical (Low density polyethylene film from Minitube AB, Sweden)
BiocompatibilityNon-cytotoxic, Non-sensitizing, Non-irritating (per ISO 10993-5, -10)Non-cytotoxic, Non-sensitizing, Non-irritating (Met requirements)
Synthetic Blood Penetration (ASTM F1670/F1670M)PassPass
Synthetic Blood Penetration at seams/non-continuous components (ASTM F1670/F1670M)PassPass
Viral Penetration (ASTM F1671/F1671M)PassPass
Viral Penetration at seams/non-continuous components (ASTM F1671/F1671M)PassPass
Tensile Strength (ASTM D882)Acceptable for 0.03mm (comparable to predicate)0.03mm - Comparable to Predicate
Puncture Resistance (ASTM F1342/F1342M)Acceptable for 0.03mm (comparable to predicate)0.03mm - Comparable to Predicate
Tear Resistance (ASTM D1004)Acceptable for 0.03mm (comparable to predicate)0.03mm - Comparable to Predicate
Device Characteristics (Thickness, Color, Sterile, Single Use)Same as predicate (0.03mm, clear, non-sterile, single use)Same as predicate (except shape/dimensions to fit different devices)
Shelf LifeNot specified for predicate, but new device is 5 years5 years (as recommended by manufacturer, storage stability report provided)

2. Sample Size Used for the Test Set and Data Provenance

The document does not explicitly state specific sample sizes for each non-clinical test (e.g., how many sleeves were tested for blood penetration). It refers to "the samples" for mechanical properties.

  • Sample Size: Not explicitly stated for each test, generally referred to as "the samples."
  • Data Provenance: Non-clinical bench testing conducted by the manufacturer for the purpose of this 510(k) submission. The document doesn't specify country of origin for the testing itself, but the submitter (Ivoclar Vivadent) is based in New York, USA, and the parent company in Liechtenstein. The material supplier is Minitube AB, Sweden. The tests are prospective, conducted specifically for this submission.

3. Number of Experts Used to Establish Ground Truth for the Test Set and Qualifications

This section is not applicable for this type of medical device submission. Ground truth, in the context of AI/ML or diagnostic devices, is typically established by medical professionals reviewing images or patient data. For a barrier sleeve, "ground truth" refers to meeting the chemical, physical, and biological performance standards, which are evaluated by laboratory testing under defined ASTM and ISO standards, not by expert medical review of "cases."


4. Adjudication Method for the Test Set

Not applicable. Adjudication methods (e.g., 2+1, 3+1) are used for resolving disagreements among human reviewers of medical data (e.g., radiologists interpreting images). The "test set" here involves laboratory measurements against established standards.


5. If a Multi-Reader Multi-Case (MRMC) Comparative Effectiveness Study Was Done

No. MRMC studies are performed to assess the impact of AI on human reader performance, typically in diagnostic imaging. This device is a physical barrier and does not involve human interpretation or AI assistance.


6. If a Standalone (Algorithm Only Without Human-in-the-Loop Performance) Was Done

Not applicable. This is not an algorithmic or software device.


7. The Type of Ground Truth Used

For this device, the "ground truth" is defined by established engineering and biocompatibility standards (e.g., ASTM F1670/F1670M for synthetic blood penetration, ISO 10993-5 for cytotoxicity). The device performance is measured against these standards and compared to the predicate device. It is not based on medical outcomes data or expert consensus in the diagnostic sense.


8. The Sample Size for the Training Set

Not applicable. This device is not an AI/ML device, so there is no concept of a "training set" for an algorithm.


9. How the Ground Truth for the Training Set Was Established

Not applicable. As per point 8, there is no training set for this device.

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Image /page/0/Picture/0 description: The image shows the logo of the U.S. Food and Drug Administration (FDA). The logo consists of two parts: the Department of Health & Human Services logo on the left and the FDA logo on the right. The FDA logo features the letters 'FDA' in a blue square, followed by the words 'U.S. FOOD & DRUG ADMINISTRATION' in blue text.

October 8, 2019

Ivoclar Vivadent, AG % Lori Aleshin Director of Quality & Regulatory Affairs Ivoclar Vivadent, Inc. 175 Pineview Drive Amherst, New York 14228

Re: K191448

Trade/Device Name: Barrier Sleeves Regulation Number: 21 CFR 878.4370 Regulation Name: Surgical Drape and Drape Accessories Regulatory Class: Class II Product Code: PEM Dated: June 26, 2019 Received: July 10, 2019

Dear Lori Aleshin:

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

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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 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 (DICE@fda.hhs.gov) or phone (1-800-638-2041 or 301-796-7100).

Sincerely,

for Srinivas Nandkumar, Ph.D. Acting 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 Healthh

Enclosure

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Indications for Use

510(k) Number (if known) K191448

Device Name Barrier Sleeve

Indications for Use (Describe)

Barrier Sleeves are intended to serve as a disposable barrier for dental instruments and equipment. This device is nonsterile and intended for single patient use only.

Type of Use (Select one or both, as applicable)

X Prescription Use (Part 21 CFR 801 Subpart D)

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

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Image /page/3/Picture/1 description: The image shows the logo for Ivoclar Vivadent. The logo is in blue and green, with the words "Ivoclar Vivadent" in a bold, sans-serif font. Below the company name is the tagline "passion vision innovation" in a smaller, sans-serif font. The logo also includes a series of green and blue dots and squares arranged in an arc above the company name.

Submitter Information:

Lori Aleshin, Director of Quality and Requlatory Affairs lvoclar Vivadent. Inc. 175 Pineview Drive Amherst, New York 14228 716-264-2045 lori.aleshin@ivoclarvivadent.com

Company: Ivoclar Vivadent, AG Bendererstrasse 2, Schaan, FL-9494, Liechtenstein +423-235-3535

Date Prepared: October 7, 2019

Device Name:

Proprietary Name:Barrier Sleeves
Classification Name:Surgical Drape and Drape Accessories
CFR Number:(878.4370)
Device Class:II
Product CodePEM

Predicate Device: Disposable Barrier Sleeves and Covers (K160232) by DENTSPLY International Inc.

Device Description: Barrier Sleeves are made of polyethylene film and are used as accessories to dental instruments and equipment used during dental procedures. These disposable barrier sleeves are offered in various shapes and sizes to fit over and cover the intended dental instruments and equipment. The disposable Barrier Sleeves slip over the ends of the respective devices, allowing for the attachment of the devices used during dental procedures. Barrier Sleeves act as a physical barrier, augmenting existing infection control techniques, and facilitate clean-up.

Indications for Use: Barrier Sleeves are intended to serve as a disposable barrier for dental instruments and equipment. This device is non-sterile and intended for single patient use only

Intended UsePredicate deviceBarrier Sleeves
IndicationsDisposable Barrier Sleeves and Covers are intendedto serve as a disposable barrier for dental instrumentsand equipment. This device is non-sterile and in-tended for single patient use only.Barrier Sleeves are intended to serveas a disposable barrier for dentalinstruments and equipment. This de-vice is non-sterile and intended forsingle patient use only.
PrecautionMeasures/ContraindicationsNoneNone
Summary of IndicationsThe indications and contraindications for the predicate and the new device arethe same.
TechnologyPredicate deviceBarrier Sleeves
Working principleDisposable Barrier Sleeves andCovers, are made ofpolyethylene film and are usedas accessories to dentalinstruments and equipmentused during dental procedures.These disposable barriersleeves and covers are offeredin various shapes and sizes tofit over and cover the intendeddental instruments andequipment. The DisposableBarrier Sleeves slip over theends of the respective devices,allowing for the attachmentand/or protrusion (whereapplicable) of those parts of thedevices used during dentalprocedures. The DisposableBarrier Cover is placed overequipment, such as dental chairhead rests or trays, to coverthose parts.Disposable Barrier Sleevesand Covers act as a physicalbarrier, augmenting existinginfection control techniques andfacilitate clean-up.Disposable Barrier Sleeves are made ofpolyethylene film and are used asaccessories to dental instruments andequipment used during dental procedures.These disposable barrier sleeves areoffered in various shapes and sizes to fitover and cover the intended dentalinstruments and equipment. TheDisposable Barrier Sleeves slip over the endsof the respective de- vices, allowing for theattachment of those parts of the devices usedduring dental procedures.Disposable Barrier Sleeves act as a physicalbarrier, augmenting existing infection controltechniques, and facilitate clean-up.
Summary Principles ofoperationThe working principle for both groups of devices is the same: the disposablebarrier sleeves are placed over the devices. The form fits over the intendeddevices. The working principle is equivalent.
Delivery forms/dosageThere are several sleeves andcovers for dental instrumentsand equipment.There are several sleeves for dentalinstruments and equipment.
Summary of Delivery formcontentIn the Clearance letter K160232 several sleeves and covers are listed. For thenew devices (Bluephase Sleeves and Vivapen Sleeves) there are supposed tobe 2 articles, which differ in the size of the sleeve. The sleeves perfectly fit overIvoclar Vivadent`s curing lights (Bluephase) and Vivapen (applicator forliquids).
Shelf lifeSupplier report is 5 years
Summary of shelf lifeShelf life for the predicate is not known. The claimed shelf life for the newdevices (Bluephase and Vivapen Sleeves) is 5 years as recommended by themanufacturer of the sleeves. Storage Stability report was provided.
Principles of operationThe disposable barrier sleeves and covers fit over and cover the intended dentalinstruments and equipment.
Summary of OperationThe principle of operation is the same.
Material CompositionPredicate deviceBarrier Sleeves
MaterialPolyethylene filmPolyethylene film
Material compositionLow density polyethylene filmLow density polyethylene film
Summary of MaterialCompositionNo difference. The predicate and the new device are manufactured by thesame supplier (Minitube AB, Sweden) and made of the same material.
BiocompatibilityPredicate deviceBarrier Sleeves
Cytotoxicity - ISO 10993-5Non-cytototoxicNon-cytototoxic
Sensitization/Irritation – ISO10993-10Non-sensitizing, non-irritatingNon-sensitizing, non-irritating
Summary of BiocompatibilityNo difference. The predicate and the new device are manufactured by thesame supplier (Minitube AB, Sweden) and made of the same material. Theresults of Biocompatibility testing are included in this submission.
Performance PropertiesPredicate deviceBarrier Sleeves
Synthetic Blood PenetrationASTM F1670/F1670MPassPass
Synthetic Blood Penetration atseams and non-continuouscomponents ASTMF1670/F1670MPassPass
Viral penetration ASTMF1671/F1671MPassPass
Viral penetration at seams andnon- continuous componentsASTM F1671/F1671MPassPass
SummaryNo difference. The predicate and the new device are manufactured by thesame supplier (Minitube AB, Sweden) and made of the same material. Theresults of Performance testing are included in this submission.
Mechanical PropertiesPredicate deviceBarrier Sleeves
Tensile strength ASTM D8820.03 mm - acceptable0.03 mm - acceptable
Puncture Resistance ASTMF1342/F1342M0.03 mm - acceptable0.03 mm - acceptable
Tear Resistance ASTM D10040.03 mm – acceptable0.03 mm - acceptable
SummaryNo difference. The predicate and the new device are manufactured by the same supplier (Minitube AB, Sweden) and made of the same material. The results of Mechanical Properties testing are included in this submission.
Device CharacteristicsPredicate deviceBarrier Sleeves
Thickness0.03 mm (Minitube AB, Sweden)0.03 mm (Minitube AB, Sweden)
ShapeCustom design to fit the intended dental instruments and equipment they coverCustom design to fit the intended dental instruments and equipment they cover
DimensionsDetermined by the size and shape of the dental instruments and equipment they coverDetermined by the size and shape of the dental instruments and equipment they cover
Colorclearclear
SterileNot sterileNot sterile
Single UseSingle use deviceSingle use device
SummaryThe new and the predicate devices are made of the same material by the same supplier (Minitube AB, Sweden). Both devices are not sterile, for single use and differ only in the shape and the dimensions as the need to fit over different types of devices

Comparison to Predicate:

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passion vision innovation

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Image /page/5/Picture/1 description: The image shows the logo for Ivoclar Vivadent, a dental company. The logo features the company name in a stylized font, with the words "passion vision innovation" written below. Above the company name is a series of green and blue dots arranged in an arc. The number 3 is in the upper right corner of the image.

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Image /page/6/Picture/1 description: The image contains the number 4 in the upper right corner. The image also contains the logo for Ivoclar Vivadent. The logo is blue and green and contains the words "Ivoclar Vivadent: passion vision innovation".

Infection Control:

The device is sold in a non-sterile condition.

Non-Clinical Performance Data:

The sponsor provided biocompatibility testing for the subject device. Direct contact with tissue is not intended. Therefore ISO 10993-1 is not applicable. Biocompatibility testing included Cytotoxicity study using the ISO Elution Method ISO 10993-5, the ISO 10993-10 Guinea Pig Maximization Sensitization Test and the ISO 10993-10 Intracutaneous Study in Rabbits-Irritation test. A Toxicological statement was also included. The performance of the proposed device, Barrier Sleeves, met the requirements of the biocompatibility testing conducted to support substantial equivalence with the primary predicate, Disposable Barrier Sleeves and Covers (K160232).

The performance testing (Bench) of the subject device, Barrier Sleeves, met the requirements of the non-clinical bench testing conducted to support substantial equivalence with the primary predicate, Disposable Barrier Sleeves and Covers (K160232). Below is a summary of the testing performed:

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Image /page/7/Picture/1 description: The image shows the logo for Ivoclar Vivadent, a dental company. The logo features the company name in a stylized font, with the words "passion vision innovation" written below. Above the company name is a series of green and blue dots and squares arranged in an arc shape.

  • ASTM F1670/F1670M Standard Test Method for Resistance of Materials Used in ● Protective Clothing to Penetration by Synthetic Blood
  • . ASTM F1671/ F1671M Standard Test Method for Resistance of Materials Used in Protective Clothing to Penetration by Blood-Borne Pathogens Using Phi-X174 Bacteriophage Penetration as a Test System
MechanicalPropertyStandardProposed DeviceBarrier SleevesPredicate DeviceDisposable BarrierSleeves and Covers(K160232)
Tensile StrengthASTM D8820.03mm - Comparableto PredicateAcceptable for0.03mm
PunctureResistanceASTMF1342/F1342M0.03mm - Comparableto PredicateAcceptable for0.03mm
Tear ResistanceASTMD10040.03mm Comparableto PredicateAcceptable for0.03mm

The range of mechanical properties for the samples is reported for the proposed devices. Barrier Sleeves. Below is a summary of the testing performed:

  • . ASTM D882 Standard Test Methods for Tensile Properties of Thin Plastic Sheeting
  • ASTM F1342/ F1342M Standard Test Method for Protective Clothing Material ● Resistance to Puncture
  • ASTM D1004 Standard Test Method for Tear Resistance (Graves Tear) of Plastic Film and Sheeting

The range of mechanical properties for the samples of the proposed devices, Barrier Sleeves, is comparable to those reported for the predicate device. Disposable Barrier Sleeves and Covers (K160232). The results indicate the subject device passed performance testing under the conditions of the tests, and support the substantial equivalence of the subject device, Barrier Sleeves to its primary predicate, Disposable Barrier Sleeves and Covers (K160232).

Clinical Performance Data:

No data from human clinical studies have been included to support the substantial equivalence of the proposed devices, Barrier Sleeves as clinical studies are not required for this medical device.

Conclusions Regarding Substantial Equivalence;

The proposed device, Barrier Sleeves, consists of dental barrier sleeves and covers which are intended to serve as a disposable barrier for dental instruments and equipment. These barrier sleeves are non-sterile and are intended for single patient use only. The proposed device, Barrier Sleeves, have the same intended use and indications for use and incorporate the same fundamental technology and working principle, as the primary predicate device, Disposable Barrier Sleeves and Covers, cleared under premarket notification (K160232). Test data to verify the

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Image /page/8/Picture/1 description: The image shows the Ivoclar Vivadent logo. The logo is blue and green. The word "Ivoclar" is on top of the word "Vivadent".

ssion vision innovation

performance of the proposed device, Barrier Sleeves, have been provided, including cytotoxicity, skin sensitization, oral mucosa irritation, synthetic blood penetration, synthetic blood penetration at seams and non-continuous components, viral penetration and viral penetration at seams and non-continuous components. The range of mechanical properties has been provided for puncture resistance, tear resistance, and tensile strength. The test results, combined with the design, intended use and mechanical property comparisons with the primary predicate device, support the substantial equivalence of the proposed Barrier Sleeves with its primary predicate device Disposable Barrier Sleeves and Covers (K160232).

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Image /page/9/Picture/1 description: The image shows the logo for Ivoclar Vivadent, a dental company. The logo features the company name in a stylized font, with the words "passion vision innovation" underneath. To the right of the logo is the number 7.

Chemical composition / Biocompatibility / Shelf life The chemical composition is identical. The biocompatibility of both device groups is the same as the devices are of the same material. The shelf life of the new devices is limited to 5 years on the recommendation of the material supplier.

Device performance The device performance is the same for both groups of barriers and sleeves.

§ 878.4370 Surgical drape and drape accessories.

(a)
Identification. A surgical drape and drape accessories is a device made of natural or synthetic materials intended to be used as a protective patient covering, such as to isolate a site of surgical incision from microbial and other contamination. The device includes a plastic wound protector that may adhere to the skin around a surgical incision or be placed in a wound to cover its exposed edges, and a latex drape with a self-retaining finger cot that is intended to allow repeated insertion of the surgeon's finger into the rectum during performance of a transurethral prostatectomy.(b)
Classification. Class II (special controls). The device, when it is an ear, nose, and throat surgical drape, a latex sheet drape with self-retaining finger cot, a disposable urological drape, a Kelly pad, an ophthalmic patient drape, an ophthalmic microscope drape, an internal drape retention ring (wound protector), or a surgical drape that does not include an antimicrobial agent, is exempt from the premarket notification procedures in subpart E of part 807 of this chapter subject to the limitations in § 878.9.