MAUDE Adverse Event Report: Institut Straumann AG BLT, ? 4.8mm RC, SLActive? 10 mm, Roxoli; Endosseous Dental Implant

Catalog Number	021.7310G
Medical Device Problem Code	Loss of Osseointegration (2408)
Health Effect - Clinical Codes	Unspecified Infection (1930); Pain (1994)
Date of Event	04/30/2026
Type of Reportable Event	Serious Injury
Event or Problem Description
The clinician reports the implant was inserted (b)(6) 2017 in ada 30.Details of surgery: implant surface not completely covered with bone.On (b)(6) 2026, loss of osseointegration was verified.Patient presented with poor oral hygiene and inadequate bone quality/quantity.The device was forwarded to the manufacturer.At the event the patient experienced: peri-implantitis and pain.No further patient complications were reported.

• Brand Name: BLT, ? 4.8mm RC, SLActive? 10 mm, Roxoli
• Common Device Name: Endosseous Dental Implant
• Manufacturer (Section D): Institut Straumann AG; peter merian-weg 12; basel 04002 ; SZ 04002
• MDR Report Key: 50413427
• Report Number: 0001222315-2026-002578
• Device Sequence Number: 13038559
• Product Code: DZE
• UDI-Device Identifier: 07630031730411
• UDI-Public: 07630031730411
• Combination Product (Y/N): N
• Initial Reporter State: NC
• Initial Reporter Country: US
• Summary Report (Y/N): N
• Device Implanted Year: 2017
• Device Explanted Year: 2026
• Serviced by Third Party (Y/N): N
• Reporter Type: Importer
• Initial Reporter Occupation: Dentist
• Type of Report: Initial
• Report Date (Section B): 08/24/2026
• Report Date (Section F): 08/24/2026

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 Expiration Date: 03/22/2021
• Device Catalogue Number: 021.7310G
• Device Lot Number: LF170
• Was Device Available for Evaluation?: Yes
• Date Returned to Manufacturer: 07/29/2026
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 08/24/2026
• Device Age: 121 MO
• Event Location: Other
• Date Report to Manufacturer: 07/29/2026
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 08/24/2026
• 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: 69 YR
• Patient Sex: Male