MAUDE Adverse Event Report: NOBEL BIOCARE USA INC 30° MULTI-UNIT ABUTMENT CC RP 4.5MM

Model Number	36623
Medical Device Problem Code	Loss of Osseointegration (2408)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	12/04/2019
Type of Reportable Event	Serious Injury
Event or Problem Description
Implant failed due to an osseointegration problem.

• Brand Name: 30° MULTI-UNIT ABUTMENT CC RP 4.5MM
• Common Device Name: ABUTMENT
• Manufacturer (Section D): NOBEL BIOCARE USA INC; 22725 savi ranch; yorba linda CA 92887 4609
• Manufacturer (Section G): NOBEL BIOCARE USA INC; 22725 savi ranch; yorba linda CA 92887 4609
• Manufacturer Contact: gayco meel ; popeweg 72; venlo 5928 -SC ; NL 5928 SC ; 623202508
• MDR Report Key: 13445361
• Report Number: 2027971-2022-037702
• Device Sequence Number: 11302959
• Product Code: DZE
• UDI-Device Identifier: 07332747032796
• UDI-Public: (01)07332747032796(10)13101996(17)230908
• Combination Product (Y/N): N
• Initial Reporter Country: CH
• PMA/510(K) Number: K072570
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2019
• Device Explanted Year: 2019
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional
• Initial Reporter Occupation: Dentist
• Type of Report: Initial

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: 09/08/2023
• Device Model Number: 36623
• Device Catalogue Number: 36623
• Device Lot Number: 13101996
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 02/03/2022
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 10/09/2020
• 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: 40 YR
• Patient Sex: Male