MAUDE Adverse Event Report: ACE SURGICAL SUPPLY CO., INC. ACE SURGICAL SUPPLY CO., INC.; Dental Implant

Model Number	204108
Medical Device Problem Codes	Failure to Osseointegrate (1863); No Apparent Adverse Event (3189)
Health Effect - Clinical Code	Insufficient Information (4580)
Date of Event	04/14/2026
Type of Reportable Event	Serious Injury
Event or Problem Description
Implant dropped during surgery.

• Brand Name: ACE SURGICAL SUPPLY CO., INC.
• Common Device Name: Dental Implant
• Manufacturer (Section D): ACE SURGICAL SUPPLY CO., INC.; 2300 riverchase center; suite 801; birmingham AL 35244
• Manufacturer (Section G): ACE SURGICAL SUPPLY CO., INC.; 2300 riverchase center; suite 801; birmingham AL 35244
• Manufacturer Contact: anissa smith ; 2300 riverchase center; suite 801; birmingham, AL 35244
• MDR Report Key: 25360391
• Report Number: 1287163-2026-10006
• Device Sequence Number: 16115570
• Product Code: DZE
• UDI-Device Identifier: 00614950004683
• UDI-Public: 00614950004683
• Combination Product (Y/N): N
• Initial Reporter State: NY
• Initial Reporter Country: US
• PMA/510(K) Number: K102981
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Dentist
• Type of Report: Initial,Followup
• Report Date (Section B): 09/30/2026

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: 204108
• Device Catalogue Number: 204108
• Device Lot Number: FG23050468
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/14/2026
• Supplement Date Received by Manufacturer: 04/14/2026
• Initial Report FDA Received Date: 06/02/2026
• Supplement Report FDA Received Date: 09/30/2026
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 05/01/2023
• 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: Unknown