MAUDE Adverse Event Report: B.T.I. BIOTECHNOLOGY INSTITUTE S.L.; INTERNA UNIVERSAL PLATFORM IMPLANT

Model Number	IIPUCA4010
Medical Device Problem Code	Loss of Osseointegration (2408)
Health Effect - Clinical Code	Fistula (1862)
Date of Event	01/10/2020
Type of Reportable Event	Serious Injury
Event or Problem Description
The clinician indicates that he placed the implant on (b)(6) 2019 and, after placing the definitive prosthesis (6 months later), the implant loses osseointegration after one week.Patient with a bone quality between iii and iv.In the event the patient experienced: vestibular fistula.
Additional Manufacturer Narrative
The batch documentation is checked and no anomalies are detected.Any manufacturing fault is ruled out.After examination of the implant, it can be verified that the implant does not show signs of misuse or signs of malfunction that could have contributed to the event.

• Common Device Name: INTERNA UNIVERSAL PLATFORM IMPLANT
• Manufacturer (Section D): B.T.I. BIOTECHNOLOGY INSTITUTE S.L.; leonardo da vinci street, 14; minano menor, alava 01510 ; SP 01510
• Manufacturer (Section G): B.T.I. BIOTECHNOLOGY INSTITUTE S.L.; leonardo da vinci street, 14; minano menor, alava 01510 ; SP 01510
• Manufacturer Contact: jose rivero ; leonardo da vinci street, 14; minano menor, alava 01510 ; SP 01510
• MDR Report Key: 19655084
• Report Number: 3004417597-2024-00001
• Device Sequence Number: 12446947
• Product Code: DZE
• UDI-Device Identifier: 08435389812203
• UDI-Public: 08435389812203
• Combination Product (Y/N): N
• Initial Reporter Country: SP
• PMA/510(K) Number: K151391
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2019
• Device Explanted Year: 2019
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Distributor
• 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
• Device Expiration Date: 07/31/2022
• Device Model Number: IIPUCA4010
• Device Lot Number: AG03087.Z
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 01/30/2020
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 01/30/2020
• Initial Report FDA Received Date: 07/02/2024
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 08/31/2017
• 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
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 53 YR
• Patient Sex: Male