MAUDE Adverse Event Report: NOBEL BIOCARE USA INC HEALING ABUTMENT CC NP Ø5X5MM

Model Number	36642
Medical Device Problem Code	Premature Separation (4045)
Health Effect - Clinical Codes	Failure of Implant (1924); Inflammation (1932)
Date of Event	06/19/2023
Type of Reportable Event	Serious Injury
Event or Problem Description
Implant failed due to part not retained on mating part.

• Brand Name: HEALING ABUTMENT CC NP Ø5X5MM
• 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: 17290729
• Report Number: 2027971-2023-098747
• Device Sequence Number: 12146818
• Product Code: DZE
• UDI-Device Identifier: 07332747034486
• UDI-Public: (01)07332747034486(10)13136230(17)250702
• Combination Product (Y/N): N
• Initial Reporter Country: FR
• PMA/510(K) Number: K133731
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2023
• 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: 07/02/2025
• Device Model Number: 36642
• Device Catalogue Number: 36642
• Device Lot Number: 13136230
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 07/04/2023
• 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: 07/10/2023
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 08/03/2022
• 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: 41 YR
• Patient Sex: Female