GLIDEWELL HT IMPLANT Ø4.3 X 13 MM
Report
- Report Number
- 3011649314-2025-00527
- Event Type
- Injury
- Date Received
- June 4, 2025
- Date of Event
- February 20, 2025
- Report Date
- September 23, 2025
- Manufacturer
- PRISMATIK DENTALCRAFT, INC.
- Product Code
- DZE
- PMA / PMN Number
- K143353
- Adverse Event
- Yes
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- FL, US
- Reporter Occupation
- DENTIST
- Health Professional
- Yes
Narratives
THE DEVICE WAS RETURNED FOR ANALYSIS HOWEVER; THE EVALUATION OF THE DEVICE IS PENDING. COMPLAINT HISTORY AND PRODUCT HISTORY RECORDS WERE REVIEWED, AND DOCUMENTATION INDICATED THE PRODUCT MET RELEASE CRITERIA. ROOT CAUSE HAS NOT BEEN IDENTIFIED. ONCE THE INVESTIGATION IS COMPLETED A SUPPLEMENTAL REPORT WILL BE SUBMITTED. MANUFACTURER INTERNAL REFERENCE NUMBER: COMP-2025-02740. THIS IS THE SECOND OF THREE COMPLAINTS FOR THE SAME PATIENT, RELATED MDR NUMBERS: 3011649314-2025-00526. 3011649314-2025-00528.
CORRECTED INFORMATION B5, G3.
DHR RESULTS: THE DHR WAS REVIEWED FOR GLIDEWELL HT IMPLANT LOT# 6232235 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: A REVIEW OF STOCK PRODUCT WAS PERFORMED FOR GLIDEWELL HT IMPLANT LOT# 6232235 AND FOUND NO ADDITIONAL PRODUCT IN STOCK. INVESTIGATION METHODS/RESULTS: THE DEVICE WAS RETURNED BUT NOT IN THE ORIGINAL PACKAGE. THE IMPLANT WAS VERIFIED TO BE A GLIDEWELL HT IMPLANT Ø4.3 X 13 MM (70-1189-IMP0012) USING THE RADIOGRAPHIC TEMPLATE (MKT-013579 REV 1 PK-4500230-112023). THERE WAS NO DEFECT OR NON-CONFORMITY OBSERVED AND THE THREADS WERE INTACT. MATTER WAS OBSERVED IN THE TREADING OF THE IMPLANT. THE COMPLAINT IS VERIFIED BASED ON THE RETURNED PART 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: "LACK OF PRIMARY STABILITY" IS A COMMON COMPLAINT IN REGARD 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 LACK OF PRIMARY STABILITY IS INCONCLUSIVE AND SPECIFIC TO EACH CASE, PROBABLE CAUSES COULD BE 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. PER THE REPORTED INFORMATION, THE PATIENT HAS A HISTORY OF HYPERTENSION, DIABETES, PERIODONTITIS, RAMPANT CARIES AND HAD INFECTED TEETH/ROOF TIPS. THE PATIENT'S TYPE OF BONE IS D1. IFU-012631 REV 1 (GLIDEWELL HT IMPLANT SYSTEM IFU) CONTAINS THE FOLLOWING STATEMENT IN THE CONTRAINDICATIONS SECTION: "GLIDEWELL HT IMPLANTS SHOULD NOT BE PLACED IN PATIENTS DISCOVERED TO BE MEDICALLY UNFIT FOR THE INTENDED TREATMENT. PRIOR TO CLINICAL INTERVENTION, PROSPECTIVE PATIENTS MUST BE THOROUGHLY EVALUATED FOR ALL KNOWN RISK FACTORS AND CONDITIONS RELATED TO ORAL SURGICAL PROCEDURES AND SUBSEQUENT HEALING. CONTRAINDICATIONS INCLUDE BUT ARE NOT LIMITED TO: VASCULAR CONDITIONS, UNCONTROLLED DIABETES, CLOTTING DISORDERS, ANTICOAGULANT THERAPY, METABOLIC BONE DISEASE, CHEMOTHERAPY OR RADIATION THERAPY, CHRONIC PERIODONTAL INFLAMMATION, INSUFFICIENT SOFT TISSUE COVERAGE, METABOLIC OR SYSTEMIC DISORDERS ASSOCIATED WITH WOUND AND/OR BONE HEALING, USE OF PHARMACEUTICALS THAT INHIBIT OR ALTER NATURAL BONE REMODELING, ANY DISORDERS WHICH INHIBIT A PATIENT'S ABILITY TO MAINTAIN ADEQUATE DAILY ORAL HYGIENE, UNCONTROLLED PARAFUNCTIONAL HABITS, INSUFFICIENT HEIGHT AND/OR WIDTH OF BONE, AND INSUFFICIENT INTERARCH SPACE" IFU-012631 REV 1 (GLIDEWELL HT IMPLANT SYSTEM IFU) CONTAINS THE FOLLOWING STATEMENT IN THE SURGICAL PROCEDURES UNDER THE 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. FOR BEST RESULTS, PLEASE OBSERVE THE FOLLOWING PRECAUTIONS: ALL DRILLING PROCEDURES SHOULD BE PERFORMED AT 2000 RPM OR LESS UNDER CONTINUAL, 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." IFU-012631 REV 1 (GLIDEWELL HT IMPLANT SYSTEM IFU) CONTAINS THE FOLLOWING STATEMENT IN THE WARNINGS 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." IFU-012631 REV 1 (GLIDEWELL HT IMPLANT SYSTEM IFU) CONTAINS THE FOLLOWING STATEMENT IN THE WARNINGS 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." MANUFACTURER INTERNAL REFERENCE NUMBER: (B)(4). THIS IS THE SECOND OF THREE COMPLAINTS FOR THE SAME PATIENT, RELATED MDR NUMBERS: 3011649314-2025-00526; 3011649314-2025-00528.
CORRECTED INFORMATION B5, G3. THE SUPPLEMENTAL #1 STATED THAT THE RECEIVED DATE (IN SECTION G3) WAS 10-JULY-2025. THE ACTUAL DATE RECEIVED IS 14-JULY-2025. MANUFACTURER INTERNAL REFERENCE NUMBER: (B)(4). THIS IS THE SECOND OF THREE COMPLAINTS FOR THE SAME PATIENT, RELATED MDR NUMBERS: 3011649314-2025-00526. 3011649314-2025-00528.
A HEALTHCARE PROFESSIONAL REPORTED A GLIDEWELL HT IMPLANT FAILED. THE PATIENT'S BONE QUALITY IS TYPE D1. THE PATIENT PRESENTED ON (B)(6) 20/25 FOR A PRIMARY PROCEDURE ON MULTIPLE TOOTH LOCATIONS #21 AND #28. PROVIDER STATED DURING IMPLANT PLACEMENT, IMPLANTS GOT STUCK DURING SURGERY, BROKE MULTIPLE TORQUE WRENCHES TRYING TO REMOVE FROM OSTEOTOMY. BONE TAP WAS USED PRIOR AND STILL TOO MUCH TORQUE TO ACHIEVE PROPER DEPTH. UPON EXAMINATION THE PROVIDER NOTICED INFECTED TEETH/ROOF TIPS AND THAT THE IMPLANTS LACKED PRIMARY STABILITY AND WERE REMOVED WITH SMALLER SIZE IMPLANTS. IT IS REPORTED THAT THE PATIENT DID NOT SUFFER HARM OR INJURY. CURRENT PATIENT STATUS IS REPORTED AS STABLE.
A HEALTHCARE PROFESSIONAL REPORTED A GLIDEWELL HT IMPLANT FAILED. THE PATIENT'S BONE QUALITY IS TYPE D1. THE PATIENT PRESENTED ON (B)(6) 2025 FOR A PRIMARY PROCEDURE ON MULTIPLE TOOTH LOCATIONS #21 AND #28. PROVIDER STATED DURING IMPLANT PLACEMENT, IMPLANTS GOT STUCK DURING SURGERY, BROKE MULTIPLE TORQUE WRENCHES TRYING TO REMOVE FROM OSTEOTOMY. BONE TAP WAS USED PRIOR AND STILL TOO MUCH TORQUE TO ACHIEVE PROPER DEPTH. UPON EXAMINATION THE PROVIDER NOTICED INFECTED TEETH/ROOF TIPS AND THAT THE IMPLANTS LACKED PRIMARY STABILITY AND WERE REMOVED. IT IS REPORTED THAT THE PATIENT DID NOT SUFFER HARM OR INJURY. CURRENT PATIENT STATUS IS REPORTED AS STABLE.
IT IS REPORTED THAT THE PATIENT DID NOT SUFFER PERMANENT HARM OR INJURY, SYMPTOMS RESOLVED AFTER IMPLANT REMOVAL.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 778385 | GLIDEWELL HT IMPLANT Ø4.3 X 13 MM | GLIDEWELL HT IMPLANT SYSTEM | DZE | PRISMATIK DENTALCRAFT, INC. | 70-1189-IMP0012 | 6232235 |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | 72 YR | Male | Required Intervention |