INCLUSIVE TAPERED IMPLANT 5.2 MMD X 11.5 MML X 4.5 MMP
Report
- Report Number
- 3011649314-2022-00649
- Event Type
- Injury
- Date Received
- November 22, 2022
- Date of Event
- August 4, 2022
- Report Date
- June 20, 2024
- Manufacturer
- PRISMATIK DENTALCRAFT, INC.
- Product Code
- DZE
- PMA / PMN Number
- K121406
- Adverse Event
- Yes
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- MI, US
- Reporter Occupation
- DENTIST
- Health Professional
- Yes
Narratives
THE DEVICE HAS NOT BEEN RETURNED. IF/WHEN THERE IS MORE INFORMATION PROVIDED, A SUPPLEMENTAL REPORT WILL BE SUBMITTED. COMPLETE DEVICE INFORMATION NOT PROVIDED WHEN ASKED. THIS IS THE THIRD OF THREE IMPLANT COMPLAINTS FOR THE SAME PATIENT. SEE MANUFACTURER REPORT FOR THE REMAINING COMPLAINT: 3011649314-2022-00647, 3011649314-2022-00648.
THE DEVICE WAS RETURNED, THE INVESTIGATION HAS BEEN COMPLETED AND THE RESULTS ARE AS FOLLOWS: DHR RESULTS: THE DHR WAS REVIEWED FOR LOT# 6022786 AND THERE WAS NO EVIDENCE DISCOVERED TO INDICATE THAT A PRODUCT DEFECT OR NON-CONFORMITY CONTRIBUTED TO THE ISSUE. THE PART MET ALL THE CRITERIA CALLED FOR IN THE PRODUCTION ROUTER. STOCK PRODUCT REVIEWED RESULTS: THE PACKAGED STOCK PRODUCT IS NOT APPLICABLE FOR REVIEW SINCE NO DEFECT WAS OBSERVED FROM THE RETURNED PRODUCT. INVESTIGATION METHODS/RESULTS: THE DEVICE WAS RETURNED BUT NOT IN ORIGINAL PACKAGE. AN ABUTMENT WAS STILL ENGAGED ON THE DEVICE. THE DEVICE WAS VERIFIED TO BE AN INCLUSIVE TAPERED IMPLANT 5.2 MMD X 11.5 MML X 4.5 MMP (70-1070-IMP0017) USING RADIOGRAPHIC TEMPLATE (GD-437-091015). THERE WAS NO DEFECT OR NON-CONFORMITY OBSERVED AND THE THREADS WERE INTACT. BONE DEBRIS WAS OBSERVED ON THE IMPLANT. THE COMPLAINT IS VERIFIED BASED ON THE RETURNED PART(S) BUT CANNOT CONFIRM THE FAILURE MODE. THERE WAS NO EVIDENCE FOUND THAT INDICATED THAT THE REPORTED ISSUE WAS CAUSED BY THE DEVICE ITSELF. ROOT CAUSE: "LOSS OF OSSEOINTEGRATION" IS A COMMON COMPLAINT IN REGARDS TO IMPLANT FAILURE. THIS OCCURS WHEN THE PATIENT'S BONE DOES NOT INTEGRATE WITH THE IMPLANT SURFACE. THE POSSIBLE RESPONSES TO THIS COMPLAINT COULD BE ATTRIBUTED TO VARIOUS CAUSES. ALTHOUGH THE ROOT CAUSE FOR LOSS OF OSSEOINTEGRATION IS INCONCLUSIVE AND SPECIFIC TO EACH CASE, PROBABLE CAUSES COULD BE THE LOSS OF PRIMARY STABILITY AT THE OSTEOTOMY SITE DUE TO INSUFFICIENT BONE OR POOR BONE QUALITY; EITHER THE BONE WAS TOO SOFT OR THE OPERATOR ERRED IN CREATING AN OSTEOTOMY BIGGER THAN THE SIZE OF THE IMPLANT DIAMETER. PREMATURE LOADING, PATIENT'S HEALTH, PERI-IMPLANTITIS, SMOKING, AND LACK OF ORAL HYGIENE MAY ALSO BE CONTRIBUTING FACTORS. IFU 3023579 REV 3.0 (INCLUSIVE DENTAL IMPLANT SYSTEM) CONTAINS THE FOLLOWING STATEMENT IN WARNING SECTION: "ABSOLUTE SUCCESS CANNOT BE GUARANTEED. FACTORS SUCH AS INFECTION, DISEASE AND INADEQUATE BONE QUALITY AND/OR QUANTITY CAN RESULT IN OSSEOINTEGRATION FAILURES FOLLOWING SURGERY OR INITIAL OSSEOINTEGRATION." IN ADDITION. IFU 3023579 REV 3.0 (INCLUSIVE DENTAL IMPLANT SYSTEM) CONTAINS THE FOLLOWING STATEMENT IN WARNING SECTION: THE IMPLANT SITE SHOULD BE INSPECTED FOR ADEQUATE BONE BY RADIOGRAPHS, PALPATIONS AND VISUAL EXAMINATION. DETERMINE THE LOCATION OF NERVES AND OTHER VITAL STRUCTURES AND THEIR PROXIMITY TO THE IMPLANT SITE BEFORE ANY DRILLING TO AVOID POTENTIAL INJURY, SUCH AS PERMANENT NUMBNESS TO THE LOWER LIP AND CHIN. ALSO, IFU 3023579 REV 3.0 (INCLUSIVE DENTAL IMPLANT SYSTEM) CONTAINS THE FOLLOWING STATEMENT IN PRECAUTION SECTION: "MINIMIZING TISSUE DAMAGE IS CRUCIAL TO SUCCESSFUL IMPLANT OSSEOINTEGRATION. IN PARTICULAR, CARE SHOULD BE TAKEN TO ELIMINATE SOURCES OF INFECTION, CONTAMINANTS, SURGICAL AND THERMAL TRAUMA. RISK OF OSSEOINTEGRATION FAILURE INCREASES AS TISSUE TRAUMA INCREASES. ALL DRILLING PROCEDURES SHOULD BE PERFORMED AT 2000 RPM OR LESS UNDER CONTINUAL AND COPIOUS IRRIGATION. ALL SURGICAL INSTRUMENTS USED MUST BE IN GOOD CONDITION AND SHOULD BE USED CAREFULLY TO AVOID DAMAGE TO IMPLANTS OR OTHER COMPONENTS. IMPLANTS SHOULD BE PLACED WITH SUFFICIENT STABILITY; HOWEVER, EXCESSIVE INSERTION TORQUE MAY RESULT IN IMPLANT FRACTURE, OR FRACTURE OR NECROSIS OF THE IMPLANT SITE. THE PROPER SURGICAL PROTOCOL SHOULD BE STRICTLY ADHERED TO. THIS COMPLAINT WILL BE KEPT ON RECORD FOR TRACK AND TRENDING PURPOSES.
CAPA 23-006. MANUFACTURER REFERENCE: (B)(4).
IT WAS REPORTED THAT THE INCLUSIVETAPERED IMPLANT FAILED. THE BONE GRADE IS NOTED AS GRADE II AND POOR HYGIENE. THE PATIENT HAS NO MEDICAL HISTORY, HOWEVER, DOES HAVE A DENTAL HISTORY OF ABSCESSED TEETH REMOVED SIX MONTHS PRIOR TO IMPLANT. THE PATIENT PRESENTED ON (B)(6) 2017 FOR IMPLANT PLACEMENT ON TOOTH #18, 20, AND 21. THIS REPORT REPRESENTS TOOTH LOCATION #18. THE PATIENT RETURNED FOUR YEARS LATER ON (B)(6) 2022 WITH COMPLAINTS OF TISSUE PAIN. UPON EXAM, THE PROVIDER NOTES THE THREADS OF THE IMPLANT ARE EXPOSED, BLEEDING TISSUE AND AN INFECTION. IT WAS AT THAT TIME THE DEVICE WAS REMOVED.
IT WAS REPORTED THAT THE HAHN TAPERED IMPLANT FAILED. THE BONE GRADE IS NOTED AS GRADE II AND POOR HYGIENE. THE PATIENT HAS NO MEDICAL HISTORY, HOWEVER, DOES HAVE A DENTAL HISTORY OF ABSCESSED TEETH REMOVED SIX MONTHS PRIOR TO IMPLANT. THE PATIENT PRESENTED ON (B)(6) 2017 FOR IMPLANT PLACEMENT ON TOOTH #18, 20, AND 21. THIS FILE REPRESENTS TOOTH LOCATION #18. THE PATIENT RETURNED ON (B)(6) 2022 WITH COMPLAINTS OF TISSUE PAIN. UPON EXAM, THE PROVIDER NOTES BONE LOSS, THE THREADS OF THE IMPLANT ARE EXPOSED, BLEEDING TISSUE AND AN INFECTION. IT WAS AT THAT TIME THE PROVIDER DETERMINED THAT THE IMPLANT LOST INTEGRATION, AND THE DEVICE WAS REMOVED. THE PATIENT IS DOING WELL.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 1917539 | INCLUSIVE TAPERED IMPLANT 5.2 MMD X 11.5 MML X 4.5 MMP | INCLUSIVE TAPERED IMPLANT | DZE | PRISMATIK DENTALCRAFT, INC. | 70-1070-IMP0017 | 6022786 |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | 70 YR | Male | Required Intervention |