MAUDE Adverse Event Report: KEYSTONE DENTAL STAGE; 3.3X12 RBM RDS STAGE1 IMP 1.8MM CL

Model Number	RSR3312-2K
Medical Device Problem Code	Loss of Osseointegration (2408)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	12/19/2019
Type of Reportable Event	Serious Injury
Event or Problem Description
Loss of osseointegration.

• Brand Name: STAGE
• Common Device Name: 3.3X12 RBM RDS STAGE1 IMP 1.8MM CL
• Manufacturer (Section D): KEYSTONE DENTAL; 154 middlesex turnpike; burlington MA 01803
• MDR Report Key: 9712987
• Report Number: 3005990499-2020-10424
• Device Sequence Number: 11598447
• Product Code: DZE
• UDI-Device Identifier: D768RSR33122K0
• UDI-Public: +D768RSR33122K0/$$3210331284795
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2017
• Device Explanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Dentist
• Type of Report: Initial
• Report Date (Section B): 02/12/2020

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: RSR3312-2K
• Device Catalogue Number: RSR3312-2K
• Device Lot Number: 28479
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 01/24/2020
• Initial Report FDA Received Date: 02/14/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 62 YR