MAUDE Adverse Event Report: INSTITUT STRAUMANN AG BLT Ø3.3MM NC, SLA® 18MM, TIZR, LOXIM; ENDOSSEOUS DENTAL IMPLANT

Model Number	SLA Roxolid BL
Medical Device Problem Code	Failure to Osseointegrate (1863)
Health Effect - Clinical Codes	Unspecified Infection (1930); Fibrosis (3167)
Date of Event	07/26/2022
Type of Reportable Event	Serious Injury
Event or Problem Description
The clinician reports the implant was inserted (b)(6) 2022 in ada 10.On (b)(6) 2022, non-osseointegration was verified.The device was forwarded to the manufacturer.At the event the patient experienced: infection and mobility.No further patient complications were reported.

• Brand Name: BLT Ø3.3MM NC, SLA® 18MM, TIZR, LOXIM
• Common Device Name: ENDOSSEOUS DENTAL IMPLANT
• Manufacturer (Section D): INSTITUT STRAUMANN AG; peter merian-weg 12; basel 04002 ; SZ 04002
• MDR Report Key: 15659423
• Report Number: 0001222315-2022-022589
• Device Sequence Number: 12181946
• Product Code: DZE
• UDI-Device Identifier: 07630031729866
• UDI-Public: 07630031729866
• Combination Product (Y/N): N
• Initial Reporter State: CT
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2022
• Device Explanted Year: 2022
• Serviced by Third Party (Y/N): N
• Reporter Type: Importer
• Initial Reporter Occupation: Dentist
• Type of Report: Initial
• Report Date (Section B): 10/24/2022
• Report Date (Section F): 09/28/2022

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?: No
• Operator of Device: Health Professional
• Device Model Number: SLA Roxolid BL
• Device Catalogue Number: 021.3518
• Device Lot Number: JFJ92
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 09/28/2022
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 10/24/2022
• Device Age: 6 MO
• Event Location: Other
• Date Report to Manufacturer: 09/28/2022
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 10/24/2022
• 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: 40 YR
• Patient Sex: Male