MAUDE Adverse Event Report: IMPLANT DIRECT SYBRON MANUFACTURING LLC SIMPLY LEGACY 3 IMPLANT; DENTAL IMPLANT

Model Number	855706U
Medical Device Problem Code	Manufacturing, Packaging or Shipping Problem (2975)
Health Effect - Clinical Codes	Failure of Implant (1924); No Information (3190)
Date of Event	06/28/2019
Type of Reportable Event	Malfunction
Event or Problem Description
Per complaint (b)(4), it was discovered during clinical procedure that a doctor was sent the wrong hex tool for a dental implant that they ordered.The patient had to be grafted for a future surgery because the procedure was not able to be completed.No additional patient consequences were reported.
Additional Manufacturer Narrative
Updated b4 for report submission date, g1 for contact information, g3 for awareness date of new information, g6 for report type and sections d9, h1, h2, h3, and h6 to report that the device was not received for analysis.Information for section a1, a2, a3, a4 were not available.When information becomes available, a supplemental report will be filed.

• Brand Name: SIMPLY LEGACY 3 IMPLANT
• Common Device Name: DENTAL IMPLANT
• Manufacturer (Section D): IMPLANT DIRECT SYBRON MANUFACTURING LLC; 3050 east hillcrest drive; thousand oaks CA 91362
• MDR Report Key: 8834825
• Report Number: 3001617766-2019-00322
• Device Sequence Number: 2119415
• Product Code: DZE
• UDI-Device Identifier: 10841307107675
• UDI-Public: 10841307107675
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• PMA/510(K) Number: K131097
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2019
• Device Explanted Year: 2019
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: health professional,user faci
• Initial Reporter Occupation: Dentist
• Type of Report: Initial,Followup
• Report Date (Section B): 10/22/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 02/19/2024
• Device Model Number: 855706U
• Device Catalogue Number: 855706U
• Device Lot Number: 135102
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 06/28/2019
• Supplement Date Received by Manufacturer: 10/20/2020
• Initial Report FDA Received Date: 07/29/2019
• Supplement Report FDA Received Date: 10/22/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1