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

Model Number	140.691
Medical Device Problem Code	Loss of Osseointegration (2408)
Health Effect - Clinical Codes	Abscess (1690); Unspecified Infection (1930); Fibrosis (3167)
Date of Event	05/15/2023
Type of Reportable Event	Serious Injury
Event or Problem Description
The clinician reports the implant was inserted on (b)(6) 2016 in ada 26.Details of surgery: primary stability not achieved and implant surface not completely covered with bone.On (b)(6) 2023, loss of osseointegration was verified.The device was forwarded to the manufacturer.At the event the patient experienced: infection, mobility and abscess.No further patient complications were reported.

• Brand Name: CM DRIVE ACQUA IMPL TI 5.0X11.5
• 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: 17334950
• Report Number: 0001222315-2023-017744
• Device Sequence Number: 6617325
• Product Code: DZE
• UDI-Device Identifier: 07899878016922
• UDI-Public: 07899878016922
• Combination Product (Y/N): N
• Initial Reporter State: NV
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2016
• Device Explanted Year: 2023
• Serviced by Third Party (Y/N): N
• Reporter Type: Importer
• Initial Reporter Occupation: Dentist
• Type of Report: Initial
• Report Date (Section B): 07/17/2023
• Report Date (Section F): 06/21/2023

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: 05/07/2018
• Device Model Number: 140.691
• Device Catalogue Number: 140.691
• Device Lot Number: 800042254I
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 06/21/2023
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 07/17/2023
• Device Age: 120 MO
• Event Location: Other
• Date Report to Manufacturer: 06/21/2023
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 07/17/2023
• 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: 77 YR
• Patient Sex: Female