MAUDE Adverse Event Report: OT MEDICAL GMBH OT - F2; 5,0 X 08

Model Number	02-1502080010
Medical Device Problem Code	Loss of Osseointegration (2408)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	05/22/2019
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
This mdr was previously submitted to the fda by keystone dental.
Event or Problem Description
No osseointegration.

• Brand Name: OT - F2
• Common Device Name: 5,0 X 08
• Manufacturer (Section D): OT MEDICAL GMBH; bremen, ; GM
• MDR Report Key: 9786939
• Report Number: 3005990499-2020-15716
• Device Sequence Number: 11386510
• Product Code: DZE
• UDI-Device Identifier: EOTM0215020800101
• UDI-Public: +EOTM0215020800101/$$323033125861808883$
• Combination Product (Y/N): N
• Initial Reporter Country: GM
• 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): 01/27/2020

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: 02-1502080010
• Device Catalogue Number: 02-1502080010
• Device Lot Number: 25861/808883
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 07/07/2019
• Initial Report FDA Received Date: 03/04/2020
• 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: Other; Required Intervention
• Patient Age: 59 YR