MAUDE Adverse Event Report: NEODENT - JJGC S.A. DRIVE SMART IMPLANT (3.3)3.5X13; ENDOSSEOUS DENTAL IMPLANT

Catalog Number	109789
Medical Device Problem Code	Failure to Osseointegrate (1863)
Health Effect - Clinical Code	Tissue Damage (2104)
Date of Event	07/23/2015
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Exemption number: e2015015.
Event or Problem Description
(b)(4).The dentist reported that 4 months after the dental implant was installed in intraoral region #20 it was verified its non- osseointegration.Twenty-five (25) ncm of primary stability was achieved and immediate load was not performed.Patient presented bone type ii.

• Brand Name: DRIVE SMART IMPLANT (3.3)3.5X13
• 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: 7013091
• Report Number: 3008261720-2017-00767
• Device Sequence Number: 1975162
• Product Code: DZE
• UDI-Device Identifier: 07898237569970
• UDI-Public: 07898237569970
• Combination Product (Y/N): N
• Initial Reporter Country: ES
• PMA/510(K) Number: K133510
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2015
• Device Explanted Year: 2015
• Reporter Type: Manufacturer
• Report Source: distributor,foreign,health pr
• Initial Reporter Occupation: Dentist
• Type of Report: Initial
• Report Date (Section B): 11/03/2015
• Report Date (Section F): 11/03/2015

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: Dentist
• Device Expiration Date: 11/01/2018
• Device Catalogue Number: 109789
• Device Lot Number: 800091427
• Other Device ID Number: 07898237569970
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/03/2015
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 11/09/2017
• Device Age: 20 MO
• Event Location: Other
• Date Report to Manufacturer: 11/03/2015
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 11/03/2015
• Initial Report FDA Received Date: 11/09/2017
• 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
• Patient Age: 47 YR
• Patient Weight: 56