MAUDE Adverse Event Report: NOBEL BIOCARE AB MULTI-UNIT ABUTMENT BMK SYST RP 4 MM; ENDOSSEOUS DENTAL IMPLANT

Model Number	29182
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	08/27/2019
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
(b)(4).Revoked asr exemption number e1997036.'report late due to asr to individual reporting transition'.
Event or Problem Description
Customer selected wrong size.

• Brand Name: MULTI-UNIT ABUTMENT BMK SYST RP 4 MM
• Common Device Name: ENDOSSEOUS DENTAL IMPLANT
• Manufacturer (Section D): NOBEL BIOCARE AB; dimbovgen 2; karlskoga, SE-69 151; SW SE-69151
• MDR Report Key: 9122413
• Report Number: 9611993-2019-17908
• Device Sequence Number: 2528012
• Product Code: DZE
• UDI-Device Identifier: 07332747003482
• UDI-Public: (01)07332747003482(10)12104866(17)210125
• Combination Product (Y/N): N
• Initial Reporter Country: CA
• PMA/510(K) Number: K961728
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Dentist
• Type of Report: Initial
• Report Date (Section B): 08/28/2019

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: 01/25/2021
• Device Model Number: 29182
• Device Catalogue Number: 29182
• Device Lot Number: 12104866
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 09/04/2019
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 08/28/2019
• Initial Report FDA Received Date: 09/26/2019
• 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: Required Intervention
• Patient Age: 58 YR