MAUDE Adverse Event Report: KEYSTONE DENTAL INC TRINX; TRI-MAX IMP TRNX D9.0 X 11MM LNG

Model Number	TRI-MAX9-11
Medical Device Problem Code	Loss of Osseointegration (2408)
Health Effect - Clinical Code	Failure of Implant (1924)
Date of Event	03/02/2020
Type of Reportable Event	Serious Injury
Event or Problem Description
Loss of osseointegration.

• Brand Name: TRINX
• Common Device Name: TRI-MAX IMP TRNX D9.0 X 11MM LNG
• Manufacturer (Section D): KEYSTONE DENTAL INC; 154 middlesex turnpike; burlington MA 01803
• MDR Report Key: 9836953
• Report Number: 3005990499-2020-30528
• Device Sequence Number: 3037329
• Product Code: DZE
• UDI-Device Identifier: D768TRIMAX9110
• UDI-Public: +D768TRIMAX9110/$$3210531290990
• 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: 2016
• Device Explanted Year: 2020
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Dentist
• Type of Report: Initial
• Report Date (Section B): 03/16/2020

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: TRI-MAX9-11
• Device Catalogue Number: TRI-MAX9-11
• Device Lot Number: 29099
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/05/2020
• Initial Report FDA Received Date: 03/16/2020
• 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: Life Threatening; Required Intervention
• Patient Age: 66 YR