MAUDE Adverse Event Report: KEYSTONE DENTAL INC RESTO; RESTORE RD 3.75X11.5 RBM THREAD IMP

Model Number	RS3811K
Medical Device Problem Code	Fracture (1260)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	10/19/2020
Type of Reportable Event	Serious Injury
Event or Problem Description
Fracture.

• Brand Name: RESTO
• Common Device Name: RESTORE RD 3.75X11.5 RBM THREAD IMP
• Manufacturer (Section D): KEYSTONE DENTAL INC; 154 middlesex turnpike; burlington MA 01803
• MDR Report Key: 11134359
• Report Number: 3005990499-2020-25797
• Device Sequence Number: 19855854
• Product Code: DZE
• UDI-Device Identifier: D768RS3811K0
• UDI-Public: +D768RS3811K0/$$7MS03668H
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2014
• Device Explanted Year: 2020
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Dentist
• Type of Report: Initial
• Report Date (Section B): 12/31/2020

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 Number: RS3811K
• Device Catalogue Number: RS3811K
• Device Lot Number: MS03668
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 12/06/2020
• Initial Report FDA Received Date: 01/07/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Congenital Anomaly; Other; Required Intervention
• Patient Age: 70 YR