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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: DENTIUMUSA SUPERLINE; DENTAL IMPLANT
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DENTIUMUSA SUPERLINE; DENTAL IMPLANT Back to Search Results
Model Number FX5008SWC
Medical Device Problem Codes Failure to Osseointegrate (1863); Osseointegration Problem (3003)
Health Effect - Clinical Code Inadequate Osseointegration (2646)
Date of Event 04/06/2020
Type of Reportable Event Serious Injury
Event or Problem Description
The dental implant fx5008swc was removed on (b)(6) 2020 due to failure to osseointegrate 1 month and 19 days after implantation.The patient has history of tobacco use and hypertension.The doctor noted periodontal disease and bone resorption during explantation.The patient has recovered without complications.
 
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Brand Name
SUPERLINE
Common Device Name
DENTAL IMPLANT
Manufacturer (Section D)
DENTIUMUSA
6761 katella ave
cypress, ca
MDR Report Key10067929
Report Number3005503242-2020-00073
Device Sequence Number10929073
Product Code DZE
UDI-Device IdentifierD755FX5008SWC0
UDI-PublicD755FX5008SWC0
Combination Product (Y/N)N
Initial Reporter CountryUS
PMA/510(K) Number
K160965
Number of Events Summarized1
Summary Report (Y/N)N
Device Implanted Year2020
Device Explanted Year2020
Reporter Type Manufacturer
Report Source health professional
Initial Reporter Occupation Dentist
Type of Report Initial
Report Date (Section B) 05/18/2020
1 Device was Involved in the Event
1 Patient was Involved in the Event
Is this an Adverse Event Report? Yes
Is this a Product Problem Report? No
Operator of Device Health Professional
Device Model NumberFX5008SWC
Device Catalogue NumberFX5008SWC
Device Lot NumberI25OB515S
Was Device Available for Evaluation? Device Returned to Manufacturer
Date Returned to Manufacturer05/13/2020
Type of Report(Section G)Thirty-Day
Initial Date Received by Manufacturer 05/13/2020
Initial Report FDA Received Date05/18/2020
Is This a Single-Use Device that was
Reprocessed and Reused on a Patient? (Y/N)		 No
Patient Sequence Number1
Outcome Attributed to Adverse Event Required Intervention;
Patient Age56 YR
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