MAUDE Adverse Event Report: OT MEDICAL GMBH OT - F3; 5.0 X 7

Model Number	03-1503070010
Medical Device Problem Code	Loss of Osseointegration (2408)
Health Effect - Clinical Code	Sinus Perforation (2277)
Date of Event	03/19/2019
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
This mdr was previously submitted to the fda by keystone dental.
Event or Problem Description
Implant loss.

• Brand Name: OT - F3
• Common Device Name: 5.0 X 7
• Manufacturer (Section D): OT MEDICAL GMBH; bremen, ; GM
• MDR Report Key: 9786945
• Report Number: 3005990499-2020-15720
• Device Sequence Number: 2495111
• Product Code: DZE
• UDI-Device Identifier: EOTM0315030700101
• UDI-Public: +EOTM0315030700101/$$322083124292804300L
• Combination Product (Y/N): N
• Initial Reporter Country: GM
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2018
• 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: 03-1503070010
• Device Catalogue Number: 03-1503070010
• Device Lot Number: 24292/804300
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/10/2019
• 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: 54 YR