MAUDE Adverse Event Report: KEYSTONE DENTAL INC GENESIS; GENESIS TAPERED IMPLANT BIOSPARK 6.5X11.5

Model Number	G21152
Medical Device Problem Code	Loss of Osseointegration (2408)
Health Effect - Clinical Code	Osteopenia/ Osteoporosis (2651)
Date of Event	09/01/2021
Type of Reportable Event	Serious Injury
Event or Problem Description
Loss of osseointegration.

• Brand Name: GENESIS
• Common Device Name: GENESIS TAPERED IMPLANT BIOSPARK 6.5X11.5
• Manufacturer (Section D): KEYSTONE DENTAL INC; 154 middlesex turnpike; burlington MA 01803
• MDR Report Key: 12480500
• Report Number: 3005990499-2021-30616
• Device Sequence Number: 14401381
• Product Code: DZE
• UDI-Device Identifier: D768G211520
• UDI-Public: +D768G211520/$$323033139200Y
• Combination Product (Y/N): N
• Initial Reporter State: TN
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2018
• Device Explanted Year: 2021
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Dentist
• Type of Report: Initial
• Report Date (Section B): 09/15/2021

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 Expiration Date: 03/30/2023
• Device Model Number: G21152
• Device Catalogue Number: G21152
• Device Lot Number: 39200
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 09/03/2021
• Initial Report FDA Received Date: 09/16/2021
• 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: Other; Required Intervention