MAUDE Adverse Event Report: NOBEL BIOCARE AB BRANEMARK SYSTEM MK III RP 3.75X13MM; ENDOSSEOUS DENTAL IMPLANT

Model Number	28887
Medical Device Problem Code	Failure to Osseointegrate (1863)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	11/14/2019
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: BRANEMARK SYSTEM MK III RP 3.75X13MM
• Common Device Name: ENDOSSEOUS DENTAL IMPLANT
• Manufacturer (Section D): NOBEL BIOCARE AB; dimbovgen 2; karlskoga, SE-69 151; SW SE-69151
• MDR Report Key: 9510108
• Report Number: 9611993-2019-31936
• Device Sequence Number: 2769439
• Product Code: DZE
• UDI-Device Identifier: 07332747004717
• UDI-Public: (01)07332747004717(10)12101950(17)221216
• Combination Product (Y/N): N
• Initial Reporter Country: FR
• PMA/510(K) Number: K925765
• 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): 11/25/2019

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: 12/16/2022
• Device Model Number: 28887
• Device Catalogue Number: 28887
• Device Lot Number: 12101950
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/25/2019
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 11/25/2019
• Initial Report FDA Received Date: 12/23/2019
• 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