MAUDE Adverse Event Report: NEODENT - JJGC S.A. CM ZYGOMATIC IMPLANT 47.5 MM; ENDOSSEOUS DENTAL IMPLANT

Model Number	109.526
Medical Device Problem Code	Failure to Osseointegrate (1863)
Health Effect - Clinical Codes	Pain (1994); Tissue Damage (2104)
Date of Event	12/08/2019
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The mdr was sent on 2020.04.23, but the message saying that a failure in the receipt by fda system occurred was only received on 2020.04.28.The lot number reported by the dentist was not verified by the crm system, so it was not considered.The information provided in this report was based on information given by the dentist in neodent¿s products warranty form that was recorded in the system and is used by both the manufacturer and the subsidiary.The original complaint and the product were received by the subsidiary and did not arrive in the manufacturer yet.When this happens, a new evaluation of the complaint will be carried out and, if necessary, a new follow-up report will be send.
Event or Problem Description
(b)(4) ¿ the dentist reported that 5 months and 03 days after the dental implant was installed in patient¿s mouth, its loss of osseointegration was observed.Moreover, the patient presented insufficient bone quality/quantity.

• Brand Name: CM ZYGOMATIC IMPLANT 47.5 MM
• Common Device Name: ENDOSSEOUS DENTAL IMPLANT
• Manufacturer (Section D): NEODENT - JJGC S.A.; av. juscelino kubitschek de; oliveira, 3291 cic; curitiba PR 81270 -200; BR 81270-200
• MDR Report Key: 10004513
• Report Number: 3008261720-2020-02303
• Device Sequence Number: 2740796
• Product Code: DZE
• UDI-Device Identifier: 07898237567808
• UDI-Public: 07898237567808
• Combination Product (Y/N): N
• Initial Reporter Country: CO
• PMA/510(K) Number: K141777
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2019
• Device Explanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: distributor,foreign,health pr
• Initial Reporter Occupation: Dentist
• Type of Report: Initial
• Report Date (Section B): 04/23/2020
• Report Date (Section F): 03/25/2020

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: 109.526
• Device Catalogue Number: 109.526
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 04/28/2020
• Event Location: Other
• Date Report to Manufacturer: 03/25/2020
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/25/2020
• Initial Report FDA Received Date: 04/28/2020
• 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: Required Intervention