MAUDE Adverse Event Report: IMPLANT DIRECT SYBRON MANUFACTURING LLC DLC DRILL STOP; DENTAL IMPLANT

Catalog Number DSN13

Device Problem Fracture (1260)

Patient Problem Failure of Implant (1924)

Event Date 08/18/2022

Event Type  Injury  

Manufacturer Narrative

Implant date and explant date are not applicable since the product was never placed and not removed.Lot information is unknown.If additional 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.

Event Description

Per complaint 84271, after clinical procedure, there was a broken or fractured component.

• Brand Name: DLC DRILL STOP
• Type of Device: DENTAL IMPLANT
• Manufacturer (Section D): IMPLANT DIRECT SYBRON MANUFACTURING LLC; 3050 east hillcrest drive; thousand oaks CA 91362
• Manufacturer Contact: marcos gutierrez ; 3050 east hillcrest drive; thousand oaks, CA 91362 ; 8184443315
• MDR Report Key: 15355336
• MDR Text Key: 299275157
• Report Number: 3001617766-2022-04483
• Device Sequence Number: 1
• Product Code: NDP
• UDI-Device Identifier: 10841307125396
• UDI-Public: 10841307125396
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: 510(K) EXCEM
• 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
• Report Date: 09/05/2022

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?: Yes
• Device Operator: Health Professional
• Device Catalogue Number: DSN13
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Initial Date Manufacturer Received: 08/18/2022
• Initial Date FDA Received: 09/05/2022
• Was Device Evaluated by Manufacturer?: No
• 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: 52 YR
• Patient Sex: Male
• Patient Weight: 84 KG