MAUDE Adverse Event Report: JJGC S.A. GM DRIVE ACQUA IMPLANT,TI,4.3X16; ENDOSSEOUS DENTAL IMPLANT

Catalog Number	140.968
Medical Device Problem Code	Loss of Osseointegration (2408)
Health Effect - Clinical Codes	Unspecified Infection (1930); Hyperresponsive to stimuli (4538)
Date of Event	06/30/2025
Type of Reportable Event	Serious Injury
Event or Problem Description
The clinician reports the implant was inserted (b)(6) 2020 in ada 13.Details of surgery: nerve encroachment and ridge augmentation.On (b)(6) 2025, loss of osseointegration was verified.Patient presented with bone type iii and bruxism.The device was forwarded to the manufacturer.At the event the patient experienced: infection, peri-implantitis and increased sensitivity.No further patient complications were reported.

• Brand Name: GM DRIVE ACQUA IMPLANT,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: 22752134
• Report Number: 0001222315-2025-002221
• Device Sequence Number: 20991037
• Product Code: DZE
• UDI-Device Identifier: 07899878025139
• UDI-Public: 07899878025139
• Combination Product (Y/N): N
• Initial Reporter State: FL
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2020
• Device Explanted Year: 2025
• Serviced by Third Party (Y/N): N
• Reporter Type: Importer
• Initial Reporter Occupation: Dentist
• Type of Report: Initial
• Report Date (Section B): 08/08/2025
• Report Date (Section F): 07/15/2025

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: 08/01/2021
• Device Catalogue Number: 140.968
• Device Lot Number: XY119
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 07/15/2025
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 08/08/2025
• Device Age: 106 MO
• Event Location: Other
• Date Report to Manufacturer: 07/15/2025
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 08/08/2025
• 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: 56 YR
• Patient Sex: Male