MAUDE Adverse Event Report: IMPLANT DIRECT SYBRON MANUFACTURING LLC DLC STEP DRILL 4.8/4.4MM (6-16MML); DENTAL IMPLANT

Catalog Number SD4.8C

Device Problem Separation Failure (2547)

Patient Problem Failure of Implant (1924)

Event Date 09/14/2021

Event Type  Injury  

Manufacturer Narrative

Other relevant history, including preexisting medical conditions were not provided.If the requested information becomes available, a supplementary report will be submitted.Implant date and explant date are not applicable since the product was never placed and not removed.Udi number is not applicable.Device evaluation results are not available.If the analysis is complete, a supplemental report will be submitted.

Event Description

Per complaint (b)(4), before clinical procedure, components could not be separated.

Manufacturer Narrative

Follow-up submitted to report device evaluation.

• Brand Name: DLC STEP DRILL 4.8/4.4MM (6-16MML)
• Type of Device: DENTAL IMPLANT
• Manufacturer (Section D): IMPLANT DIRECT SYBRON MANUFACTURING LLC; 3050 east hillcrest drive; thousand oaks CA 91362
• Manufacturer Contact: karen manalili ; 3050 east hillcrest drive; thousand oaks, CA 91362 ; 8057785914
• MDR Report Key: 12506353
• MDR Text Key: 272471350
• Report Number: 3001617766-2021-05491
• Device Sequence Number: 1
• Product Code: DZI
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K200265
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Health Professional,User Facility
• Reporter Occupation: Dentist
• Remedial Action: Inspection
• Type of Report: Initial,Followup
• Report Date: 12/10/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 09/21/2021
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Catalogue Number: SD4.8C
• Device Lot Number: 172741
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 12/02/2021
• Is the Reporter a Health Professional?: Yes
• Date Manufacturer Received: 12/08/2021
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 12/23/2020
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Patient Outcome(s): Required Intervention
• Patient Age: 45 YR
• Patient Sex: Female
• Patient Weight: 75 KG