MAUDE Adverse Event Report: KEYSTONE DENTAL GENESIS; GEN TPRD IMP BIOSPRKSURFACE6.5X11.5

Model Number	G21152
Medical Device Problem Code	Failure to Osseointegrate (1863)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	10/23/2019
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
This mdr was previously submitted to the fda by keystone dental.(b)(4).
Event or Problem Description
Failure to osseointegrate.

• Brand Name: GENESIS
• Common Device Name: GEN TPRD IMP BIOSPRKSURFACE6.5X11.5
• Manufacturer (Section D): KEYSTONE DENTAL; 154 middlesex turnpike; burlington MA 01803
• MDR Report Key: 9713862
• Report Number: 3005990499-2020-10332
• Device Sequence Number: 3654396
• Product Code: DZE
• UDI-Device Identifier: D768G211520
• UDI-Public: +D768G211520/$$3210430285583
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• 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): 01/09/2020

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: G21152
• Device Catalogue Number: G21152
• Device Lot Number: 28558
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 10/24/2019
• 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: 64 YR