MAUDE Adverse Event Report: KEYSTONE DENTAL INC STAGE; 4.1X12 RBM STAGE1 IMP 1.8 COL

Model Number	RSR4112-2K
Medical Device Problem Code	Loss of Osseointegration (2408)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	08/07/2020
Type of Reportable Event	Serious Injury
Event or Problem Description
Loss of osseointegration.

• Brand Name: STAGE
• Common Device Name: 4.1X12 RBM STAGE1 IMP 1.8 COL
• Manufacturer (Section D): KEYSTONE DENTAL INC; 154 middlesex turnpike; burlington MA 01803
• MDR Report Key: 11134488
• Report Number: 3005990499-2021-25829
• Device Sequence Number: 4125129
• Product Code: DZE
• UDI-Device Identifier: D768RSR41122K0
• UDI-Public: +D768RSR41122K0/$$3220531338720
• Combination Product (Y/N): N
• Initial Reporter Country: TW
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2019
• Device Explanted Year: 2020
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Dentist
• Type of Report: Initial
• Report Date (Section B): 01/06/2021

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: RSR4112-2K
• Device Catalogue Number: RSR4112-2K
• Device Lot Number: 33872
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 12/07/2020
• 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