MAUDE Adverse Event Report: IMPLANT DIRECT SYBRON MANUFACTURING LLC LEGACY BALL ABUTMENT; DENTAL IMPLANT

Catalog Number 8035-72

Device Problem Failure to Osseointegrate (1863)

Patient Problems Failure of Implant (1924); Unspecified Infection (1930); Pain (1994); Osteopenia/ Osteoporosis (2651)

Event Date 03/10/2021

Event Type  Injury  

Event Description

Per complaint (b)(4), after clinical procedure, patient experienced loss of implant to osseointegrate.

Manufacturer Narrative

Patient's age, weight were not provided.If the requested information becomes available, a supplementary report will be submitted.Device evaluation results are not available.If the analysis is complete, a supplemental report will be submitted.

Manufacturer Narrative

Follow-up submitted to report device evaluation.Updated section b4 for report submission date and b6 to report device evaluation results.Updated d9 for device return date, g1 for follow-up report submitter, g3 for awareness date and g6 for report type and follow-up number.Updated h2 for follow-up type, h3 for device evaluation status and h6 method, result and conclusion codes.Patient age and sex are unknown.

• Brand Name: LEGACY BALL ABUTMENT
• 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: 12770620
• MDR Text Key: 280460358
• Report Number: 3001617766-2021-06531
• Device Sequence Number: 1
• Product Code: NHA
• UDI-Device Identifier: 10841307110880
• UDI-Public: 10841307110880
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K081101
• 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: 01/06/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 11/08/2021
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Health Professional
• Device Catalogue Number: 8035-72
• Device Lot Number: 163201
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/23/2021
• Is the Reporter a Health Professional?: Yes
• Date Manufacturer Received: 01/05/2022
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 06/12/2020
• 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 Sex: Female