MAUDE Adverse Event Report: ACE SURGICAL SUPPLY CO., INC. ACE SURGICAL SUPPLY CO., INC.; DENTAL IMPLANT

Model Number	205180
Medical Device Problem Code	Failure to Osseointegrate (1863)
Health Effect - Clinical Code	Insufficient Information (4580)
Date of Event	02/27/2026
Type of Reportable Event	Serious Injury
Event or Problem Description
Implant failed to osseointegrate.

• 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: 25449708
• Report Number: 1287163-2026-00002
• Device Sequence Number: 12222504
• Product Code: DZE
• UDI-Device Identifier: 00614950004799
• UDI-Public: 00614950004799
• 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
• Report Date (Section B): 03/29/2026

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: 205180
• Device Catalogue Number: 205180
• Device Lot Number: FG22090292
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/27/2026
• Initial Report FDA Received Date: 06/09/2026
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 08/31/2022
• 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 Sex: Unknown