MAUDE Adverse Event Report: THOMMEN MEDICAL AG ELEMENT LC INICELL, PF 4,0, E 4,0, L 11,0; DENTAL IMPLANT

Model Number	4.23.724
Medical Device Problem Code	Loss of Osseointegration (2408)
Health Effect - Clinical Code	No Code Available (3191)
Date of Event	08/22/2018
Type of Reportable Event	Serious Injury
Event or Problem Description
Loss of osseointegration.

• Brand Name: ELEMENT LC INICELL, PF 4,0, E 4,0, L 11,0
• Common Device Name: DENTAL IMPLANT
• Manufacturer (Section D): THOMMEN MEDICAL AG; neckarsulmstrasse 28; grenchen, 2540 ; SZ 2540
• MDR Report Key: 8100144
• Report Number: 3003184527-2018-01192
• Device Sequence Number: 11167883
• Product Code: DZE
• UDI-Device Identifier: 07640156470185
• UDI-Public: 7640156470185
• Combination Product (Y/N): N
• Initial Reporter Country: NL
• PMA/510(K) Number: K093615
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2017
• Device Explanted Year: 2018
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Dentist
• Type of Report: Initial
• Report Date (Section B): 09/18/2018

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: Health Professional
• Device Expiration Date: 10/14/2018
• Device Model Number: 4.23.724
• Device Lot Number: 4576
• Was Device Available for Evaluation?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 11/18/2018
• Initial Report FDA Received Date: 11/24/2018
• 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: 63 YR