MAUDE Adverse Event Report: ACE SURGICAL TRI CAM IMPLANT

Model Number	305010
Medical Device Problem Code	Failure to Osseointegrate (1863)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	09/02/2021
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The consumer reported that the patient had a tooth type of 2, the consumer also reported that the time of loss in relation to implantation was before prosthetic restoration, primary stability & osseointegration was achieved.
Event or Problem Description
The consumer reported that the patient had a tooth type of 2, the consumer also reported that the time of loss in relation to implantation was before prosthetic restoration, primary stability & osseointegration was achieved.

• Brand Name: TRI CAM IMPLANT
• Common Device Name: TRI CAM IMPLANT
• Manufacturer (Section D): ACE SURGICAL; 1034 pearl st; brockton MA 02301
• Manufacturer (Section G): ACE SURGICAL; 1034 pearl street; brockton MA 02301
• Manufacturer Contact: james weatherby ; 1034; brockton, MA 02301 ; 8004413100
• MDR Report Key: 16714284
• Report Number: 1287163-2023-54033
• Device Sequence Number: 16592213
• Product Code: DZE
• UDI-Device Identifier: 00614950005277
• UDI-Public: 00614950005277
• Combination Product (Y/N): N
• Initial Reporter Country: PO
• 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): 01/19/2023

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: 305010
• Device Catalogue Number: 305010
• Device Lot Number: 20100083
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 01/09/2023
• Initial Report FDA Received Date: 04/11/2023
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• 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: 74 YR
• Patient Sex: Male