MAUDE Adverse Event Report: THOMMEN MEDICAL AG CONTACT IMPL., PF Ø 4,5, E Ø 3,5, L 11,0; DENTAL IMPLANT

Model Number	4.13.221
Medical Device Problem Code	Failure to Osseointegrate (1863)
Health Effect - Clinical Code	No Code Available (3191)
Date of Event	10/10/2018
Type of Reportable Event	Serious Injury
Event or Problem Description
No osseointegration, patient smoker.(b)(6) and (b)(6) are same patient.

• Brand Name: CONTACT IMPL., PF Ø 4,5, E Ø 3,5, L 11,0
• Common Device Name: DENTAL IMPLANT
• Manufacturer (Section D): THOMMEN MEDICAL AG; neckarsulmstrasse 28; grenchen, 2540 ; SZ 2540
• MDR Report Key: 8277504
• Report Number: 3003184527-2018-01386
• Device Sequence Number: 1691456
• Product Code: DZE
• UDI-Device Identifier: 07640156471694
• UDI-Public: 7640156471694
• Combination Product (Y/N): N
• Initial Reporter Country: CH
• PMA/510(K) Number: K051502
• 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): 10/10/2018

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: 02/07/2019
• Device Model Number: 4.13.221
• Device Lot Number: 10141
• Was Device Available for Evaluation?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 12/08/2018
• Initial Report FDA Received Date: 01/25/2019
• 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: 62 YR