BEUDAMED
    FDA Adverse Event Injury Summary report: N

    INCLUSIVE TAPERED IMPLANT 3.7 MMD X 8 MML X 3.5 MMP

    MDR report key: 9079492 · Received September 17, 2019

    Report

    Report Number
    3011649314-2019-00528
    Event Type
    Injury
    Date Received
    September 17, 2019
    Date of Event
    June 30, 2019
    Report Date
    December 18, 2019
    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

    Narratives

    Additional Manufacturer Narrative · 0

    DATE OF REPORT: IS "09/17/2019", WAS BLANK.

    Additional Manufacturer Narrative · 0

    THE DEVICE INVESTIGATION HAS BEEN COMPLETED AND THE RESULTS ARE AS FOLLOWS: RETURNED SAMPLE: THE IMPLANT WAS RETURNED BUT NOT IN ORIGINAL PACKAGE. THE PART WAS MEASURED AND VERIFIED TO BE AN INCLUSIVE TAPERED IMPLANT 3.7 MM X 8 MM X 3.5 MM (70-1070-IMP0005). COMPLAINT INVESTIGATOR MEASURED THE CRITICAL PARAMETERS AGAINST DWG 3003649 REV 8.0 FROM DHR AND FOUND NO DEVIATION. THE IMPLANT THREAD WAS INTACT AND THE INTERNAL FEATURE WAS FINE. THERE WAS NO DEFECT OR NON-CONFORMITY OBSERVED. BONE DEBRIS WAS OBSERVED FROM THE IMPLANT. DEVICE HISTORY RECORD: THE DHR WAS REVIEWED 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. 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 MENTIONED BELOW. SMOKING IS KNOWN TO INHIBIT LOCAL WOUND HEALING AND MAY AFFECT SURVIVAL OF IMPLANTS. SMOKING HAS A STRONG INFLUENCE ON THE COMPLICATION RATES OF IMPLANTS. IT CAUSES SIGNIFICANTLY MORE MARGINAL BONE LOSS AFTER IMPLANT PLACEMENT, INCREASED THE INCIDENCE OF PERI-IMPLANTITIS (DEEP MUCOSAL POCKETS AROUND DENTAL IMPLANTS, INFLAMMATION OF THE PERI-IMPLANT MUCOSA, AND INCREASED RESORPTION OF PERI-IMPLANT BONE, AND AFFECTS THE SUCCESS RATES OF BONE GRAFTS. ALTHOUGH THE ROOT CAUSE FOR FAILURE TO OSSEOINTEGRATE 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 TO THE LACK OF OSSEOINTEGRATION. IN THIS CASE, THE PHYSICIAN REPORTED THE PATIENT HAD POOR HYGIENE MAY HAVE CONTRIBUTED TO THE IMPLANT FAILURE. 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." THE IFU ALSO 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.

    Additional Manufacturer Narrative · 1

    THE DEVICE HAS BEEN RETURNED. ONCE THE INVESTIGATION IS COMPLETE A SUPPLEMENTAL REPORT WILL BE SUBMITTED. THIS REPORT IS FOR THE 1ST OF 2 FAILED IMPLANTS ON THE SAME PATIENT. SEE REPORT 3011649314-2019-00529 ((B)(6)) FOR THE REPORT ON THE 2ND IMPLANT.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT A HAHN TAPERED IMPLANT FAILED. THE DOCTOR REPORTED THAT THE IMPLANT WAS PLACED ON (B)(6) 2017 AT TOOTH LOCATION #13. THE PATIENT RETURNED ON (B)(6) 2019 COMPLAINING OF PAIN. UPON EXAMINATION, THE DOCTOR NOTED SWELLING AND INFECTION AT THE IMPLANT SITE. THE IMPLANT WAS THEN REMOVED DUE TO LOSS OF OSSEOINTEGRATION. THE PATIENT CURRENTLY HAS A BONE GRAFT AT THE IMPLANT SITE. THE PATIENT HAS A HISTORY OF SMOKING. THERE WAS NO ABNORMALITY NOTED WITH THE IMPLANT ITSELF.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    871934 INCLUSIVE TAPERED IMPLANT 3.7 MMD X 8 MML X 3.5 MMP INCLUSIVE TAPERED IMPLANT DZE PRISMATIK DENTALCRAFT, INC. 70-1070-IMP0005 6021817

    Patients

    Seq Age Sex Outcome Treatment
    1 Required Intervention