MAUDE Adverse Event Report: ACE SURGICAL INTERNAL HEX IMPLANTD; DENTAL IMPLANT

Model Number	204113
Medical Device Problem Code	Failure to Osseointegrate (1863)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	04/14/2021
Type of Reportable Event	Serious Injury
Event or Problem Description
Tooth h11 extracted, and placed alloderm min/ dom mix, from life net.
Additional Manufacturer Narrative
Visual evaluation of product under 65x magnification showed no signs of physical defects.

• Brand Name: INTERNAL HEX IMPLANTD
• Common Device Name: DENTAL IMPLANT
• Manufacturer (Section D): ACE SURGICAL; 1034 pearl st; brockton MA 02301
• Manufacturer (Section G): ACE SURGICAL; 1034 pearl st; brockton MA 02301
• Manufacturer Contact: franco desruisseaux ; 1034 pearl st; brockton, MA 02301
• MDR Report Key: 13180113
• Report Number: 1287163-2022-01034
• Device Sequence Number: 17570474
• Product Code: DZE
• UDI-Device Identifier: 00614950004713
• UDI-Public: 00614950004713
• Combination Product (Y/N): N
• Initial Reporter State: RI
• Initial Reporter Country: US
• PMA/510(K) Number: K102981
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2021
• Device Explanted Year: 2021
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional
• Initial Reporter Occupation: Dentist
• Type of Report: Initial
• Report Date (Section B): 09/29/2021

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: 204113
• Device Catalogue Number: 204113
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 01/03/2022
• Initial Report FDA Received Date: 01/06/2022
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 71 YR
• Patient Sex: Female