MAUDE Adverse Event Report: CM DRIVE ACQUA IMPL TI 5.0X11.5; ENDOSSEOUS DENTAL IMPLANT

Model Number	140.691
Medical Device Problem Code	Fracture (1260)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	08/24/2021
Type of Reportable Event	Serious Injury
Event or Problem Description
The clinician reports the implant was inserted (b)(6) 2016 in ada 31.On (b)(6) 2021, fracture of the implant was verified.The device was forwarded to the manufacturer.There were no patient operative or post-operative complications reported.

• Brand Name: CM DRIVE ACQUA IMPL TI 5.0X11.5
• Common Device Name: ENDOSSEOUS DENTAL IMPLANT
• MDR Report Key: 12633758
• Report Number: 0001222315-2021-17259
• Device Sequence Number: 11834647
• Product Code: DZE
• UDI-Device Identifier: 07899878016922
• UDI-Public: 07899878016922
• Combination Product (Y/N): N
• Initial Reporter State: UT
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2016
• Device Explanted Year: 2021
• Serviced by Third Party (Y/N): N
• Reporter Type: Importer
• Initial Reporter Occupation: Dentist
• Type of Report: Initial
• Report Date (Section B): 10/14/2021
• Report Date (Section F): 09/20/2021

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 Expiration Date: 04/07/2017
• Device Model Number: 140.691
• Device Catalogue Number: 140.691
• Device Lot Number: 800185357I
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 09/20/2021
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 10/14/2021
• Device Age: 112 MO
• Event Location: Other
• Date Report to Manufacturer: 09/20/2021
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 10/14/2021
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 39 YR