MAUDE Adverse Event Report: NOBEL BIOCARE AB TREFOIL IMPLANT CC RP 5.0X13+4.5MM; ENDOSSEOUS DENTAL IMPLANT

Model Number	38321
Medical Device Problem Code	Osseointegration Problem (3003)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	05/17/2023
Type of Reportable Event	Serious Injury
Event or Problem Description
Implant failed due to an osseointegration problem.

• Brand Name: TREFOIL IMPLANT CC RP 5.0X13+4.5MM
• Common Device Name: ENDOSSEOUS DENTAL IMPLANT
• Manufacturer (Section D): NOBEL BIOCARE AB; dimbovägen 2; karlskoga 69151 ; SW 69151
• Manufacturer (Section G): NOBEL BIOCARE AB; dimbovägen 2; karlskoga 69151 ; SW 69151
• Manufacturer Contact: gayco meel ; popeweg 72; venlo 5928 -SC ; NL 5928 SC ; 623202508
• MDR Report Key: 17130068
• Report Number: 9611993-2023-076475
• Device Sequence Number: 7377106
• Product Code: DZE
• UDI-Device Identifier: 07332747102888
• UDI-Public: (01)07332747102888(10)12095847(17)220918
• Combination Product (Y/N): N
• Initial Reporter Country: SP
• PMA/510(K) Number: K172352
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2021
• 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: 09/18/2022
• Device Model Number: 38321
• Device Catalogue Number: 38321
• Device Lot Number: 12095847
• 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: 06/14/2023
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 10/20/2017
• 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 Sex: Female