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

Model Number	855208U
Medical Device Problem Code	Positioning Problem (3009)
Health Effect - Clinical Codes	Failure of Implant (1924); Fibrosis (3167)
Date of Event	05/24/2018
Type of Reportable Event	Serious Injury
Event or Problem Description
Per complaint (b)(4) after clinical procedure, patient experienced failure of implant to integrate.
Additional Manufacturer Narrative
Follow-up submitted to report device evaluation.Section a2, no information was available.Updated section b4 for report submission date and b6 to report device evaluation results.Section d7, no information was available.Updated d10 for device return date, g1-g2 for follow-up report submitter, g4 for awareness date and g7 for report type and follow-up number.Updated h2 for follow-up type, h3 for device evaluation status and h6 method, result and conclusion codes.Updated d4 for lot # to include ni for no information available.Section d4 for expiration date, h4 for device manufacture date, no information was available.This report is submitted late and is captured within capa-1374.

• 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: 9387981
• Report Number: 3001617766-2019-05327
• Device Sequence Number: 11258965
• Product Code: DZE
• UDI-Device Identifier: 10841307107897
• UDI-Public: 10841307107897
• Combination Product (Y/N): N
• Initial Reporter State: FL
• Initial Reporter Country: US
• PMA/510(K) Number: K090234
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2018
• Reporter Type: Manufacturer
• Report Source: health professional,user faci
• Initial Reporter Occupation: Dentist
• Remedial Action: Inspection
• Type of Report: Initial,Followup
• Report Date (Section B): 04/24/2020

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 Model Number: 855208U
• Device Catalogue Number: 855208U
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 12/17/2019
• Initial Date Received by Manufacturer: 11/01/2019
• Supplement Date Received by Manufacturer: 01/10/2020
• Initial Report FDA Received Date: 11/27/2019
• Supplement Report FDA Received Date: 04/24/2020
• 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