MAUDE Adverse Event Report: THOMMEN MEDICAL AG CONTACT RC INICELL, PF 6,0, E 5,0, L 12,5; DENTAL IMPLANT

Model Number	4.23.255
Medical Device Problem Code	Failure to Osseointegrate (1863)
Health Effect - Clinical Code	No Code Available (3191)
Date of Event	01/22/2018
Type of Reportable Event	Serious Injury
Event or Problem Description
No primary stability achieved, instability.

• Brand Name: CONTACT RC INICELL, PF 6,0, E 5,0, L 12,5
• Common Device Name: DENTAL IMPLANT
• Manufacturer (Section D): THOMMEN MEDICAL AG; neckarsulmstrasse 28; grenchen, 2540 ; SZ 2540
• MDR Report Key: 7345442
• Report Number: 3003184527-2018-00225
• Device Sequence Number: 554923
• Product Code: DZE
• UDI-Device Identifier: 07640156470901
• UDI-Public: 7640156470901
• Combination Product (Y/N): N
• Initial Reporter Country: GM
• PMA/510(K) Number: K090154
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2018
• Device Explanted Year: 2018
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Dentist
• Type of Report: Initial
• Report Date (Section B): 02/19/2018

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: Dentist
• Device Expiration Date: 11/20/2020
• Device Model Number: 4.23.255
• Device Lot Number: 13122
• Was Device Available for Evaluation?: Yes
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/12/2018
• Initial Report FDA Received Date: 03/16/2018
• 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: Other
• Patient Age: 87 YR