MAUDE Adverse Event Report: NOBEL BIOCARE USA, LLC REPLACE SELECT TAPERED TIU 6.0 6.0X8MM; ENDOSSEOUS DENTAL IMPLANT

Model Number	36110
Medical Device Problem Code	Failure to Osseointegrate (1863)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	10/15/2019
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
(b)(4).
Event or Problem Description
Implant failed due to a failure to osseointegrate.

• Brand Name: REPLACE SELECT TAPERED TIU 6.0 6.0X8MM
• Common Device Name: ENDOSSEOUS DENTAL IMPLANT
• Manufacturer (Section D): NOBEL BIOCARE USA, LLC; 22715 savi ranch parkway; yorba linda CA 92887 7149
• MDR Report Key: 9374266
• Report Number: 2027971-2019-03906
• Device Sequence Number: 14219604
• Product Code: DZE
• UDI-Device Identifier: 07332747022629
• UDI-Public: (01)07332747022629(10)13057051(17)221126
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K023113
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2019
• Device Explanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Dentist
• Type of Report: Initial
• Report Date (Section B): 10/28/2019

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: 11/26/2022
• Device Model Number: 36110
• Device Catalogue Number: 36110
• Device Lot Number: 13057051
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 10/28/2019
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 10/28/2019
• Initial Report FDA Received Date: 11/26/2019
• 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: 64 YR