MAUDE Adverse Event Report: JJGC S.A. CM DRIVE IMPL TI 4.3X16; ENDOSSEOUS DENTAL IMPLANT

Model Number	109.629
Medical Device Problem Code	Fracture (1260)
Health Effect - Clinical Code	Pain (1994)
Date of Event	02/22/2021
Type of Reportable Event	Serious Injury
Event or Problem Description
The clinician reports the implant was inserted on (b)(6) 2015 in ada 20.On (b)(6) 2021, fracture of the implant was verified.No product was returned to the manufacturer.At the event the patient experienced: pain.No further patient complications were reported.

• Brand Name: CM DRIVE IMPL TI 4.3X16
• Common Device Name: ENDOSSEOUS DENTAL IMPLANT
• Manufacturer (Section D): JJGC S.A.; av. juscelino kubitschek de; oliveira, 3291 cic; curitiba PR 81270 -200; BR 81270-200
• MDR Report Key: 16487806
• Report Number: 0001222315-2023-005338
• Device Sequence Number: 6919515
• Product Code: DZE
• UDI-Device Identifier: 07898237568775
• UDI-Public: 07898237568775
• Combination Product (Y/N): N
• Initial Reporter State: VA
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2015
• 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): 03/06/2023
• Report Date (Section F): 02/08/2023

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: 06/01/2019
• Device Model Number: 109.629
• Device Catalogue Number: 109.629
• Device Lot Number: 800136397
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 03/06/2023
• Device Age: 80 MO
• Event Location: Other
• Date Report to Manufacturer: 02/08/2023
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 03/06/2023
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• 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 Sex: Male