MAUDE Adverse Event Report: BIOMET 3I 3I T3 TAPERED IMPLANT 5/4 X 15MM; DENTAL IMPLANT

Model Number	BOPT5415
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Unspecified Infection (1930); Inflammation (1932); Pain (1994); Swelling (2091); No Code Available (3191)
Date of Event	09/28/2020
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Zimmer biomet (b)(4).Weight unknown / not provided.A summary investigation has been completed for infection events identifying that a definitive root cause cannot be identified due to the wide range of external (non-design/ non-manufacturing related) factors potentially impacting the sterility of the implant and its environment.Should additional information be received which indicates that the device may have caused or contributed to the infection event, an additional report will be submitted.Summary reporting.
Event or Problem Description
It was reported that implant at tooth site # 28 was placed on (b)(6) 2020, on (b)(6) 2020 during post op appointment, patient complained of soreness but wound looked good, recommended rinses and heat to jaw.Patient returned on (b)(6) 2020 with pain and tenderness buccally and lingually.Proceeded to explant # 28 due to infection.Site grafted.Patient to return in 4 months for implant re-placement.Symptoms as a result of the event: infection, tenderness, swelling, inflammation & pain.

• Brand Name: 3I T3 TAPERED IMPLANT 5/4 X 15MM
• Common Device Name: DENTAL IMPLANT
• Manufacturer (Section D): BIOMET 3I; 4555 riverside drive; palm beach gardens FL 33410
• MDR Report Key: 11242935
• Report Number: 0001038806-2021-00126
• Device Sequence Number: 3717948
• Product Code: DZE
• UDI-Device Identifier: 00844868029847
• UDI-Public: (01)00844868029847(17)240206(10)2019011578(241)BOPT5415
• Combination Product (Y/N): N
• Initial Reporter State: TN
• Initial Reporter Country: US
• PMA/510(K) Number: K122300
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2020
• Device Explanted Year: 2020
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Dentist
• Type of Report: Initial
• Report Date (Section B): 01/28/2021

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: Lay User/Patient
• Device Expiration Date: 02/06/2024
• Device Model Number: BOPT5415
• Device Catalogue Number: BOPT5415
• Device Lot Number: 2019011578
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 01/15/2021
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 01/15/2021
• Initial Report FDA Received Date: 01/28/2021
• 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: Required Intervention
• Patient Age: 64 YR