MAUDE Adverse Event Report: INSTITUT STRAUMANN AG BL, Ø 3.3 MM NC, SLACTIVE 14 MM; ENDOSSEOUS DENTAL IMPLANT

Catalog Number	021.2114
Medical Device Problem Code	Loss of Osseointegration (2408)
Health Effect - Clinical Codes	Unspecified Infection (1930); Pain (1994); Fibrosis (3167)
Date of Event	02/12/2024
Type of Reportable Event	Serious Injury
Event or Problem Description
The clinician reports the implant was inserted (b)(6) 2013 in ada 10.Details of surgery: ridge augmentation.On (b)(6) 2024, loss of osseointegration was verified.Patient presented with poor oral hygiene.The device was forwarded to the manufacturer.At the event the patient experienced: peri-implantitis, pain and mobility.No further patient complications were reported.

• Brand Name: BL, Ø 3.3 MM NC, SLACTIVE 14 MM
• Common Device Name: ENDOSSEOUS DENTAL IMPLANT
• Manufacturer (Section D): INSTITUT STRAUMANN AG; peter merian-weg 12; basel 04002 ; SZ 04002
• MDR Report Key: 19062155
• Report Number: 0001222315-2024-000883
• Device Sequence Number: 12269398
• Product Code: DZE
• UDI-Device Identifier: 07630031706379
• UDI-Public: 07630031706379
• Combination Product (Y/N): N
• Initial Reporter State: CO
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2013
• Device Explanted Year: 2024
• Serviced by Third Party (Y/N): N
• Reporter Type: Importer
• Initial Reporter Occupation: Dentist
• Type of Report: Initial
• Report Date (Section B): 04/08/2024
• Report Date (Section F): 03/13/2024

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: 06/30/2013
• Device Catalogue Number: 021.2114
• Device Lot Number: L1562
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 03/13/2024
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 04/08/2024
• Device Age: 188 MO
• Event Location: Other
• Date Report to Manufacturer: 03/13/2024
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 04/08/2024
• 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: 72 YR
• Patient Sex: Male