MAUDE Adverse Event Report: NEODENT - JJGC S.A. TI DRIVE ACQUA IMPLANT (5.0) 5.0X8; ENDOSSEOUS DENTAL IMPLANT

Catalog Number	140762
Medical Device Problem Code	Failure to Osseointegrate (1863)
Health Effect - Clinical Codes	Fistula (1862); Swelling (2091); Tissue Damage (2104)
Date of Event	02/16/2016
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Exemption number: e2015015.
Event or Problem Description
(b)(4).The dentist reported that 40 days after the dental implant was installed in intraoral region #3 it was verified its non- osseointegration.Twenty ncm of primary stability was achieved and immediate load was not executed.The patient presented insufficient bone quality/quantity (bone type iv).

• Brand Name: TI DRIVE ACQUA IMPLANT (5.0) 5.0X8
• 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: 7017321
• Report Number: 3008261720-2017-01591
• Device Sequence Number: 1184170
• Product Code: DZE
• UDI-Device Identifier: 07899878017172
• UDI-Public: 07899878017172
• Combination Product (Y/N): N
• Initial Reporter Country: BR
• PMA/510(K) Number: K133592
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2016
• Device Explanted Year: 2016
• Reporter Type: Manufacturer
• Report Source: distributor,foreign,health pr
• Initial Reporter Occupation: Dentist
• Type of Report: Initial
• Report Date (Section B): 03/18/2016
• Report Date (Section F): 03/18/2016

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: 08/13/2017
• Device Catalogue Number: 140762
• Device Lot Number: 800206299
• Other Device ID Number: 07899878017172
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 03/18/2016
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 11/10/2017
• Device Age: 6 MO
• Event Location: Other
• Date Report to Manufacturer: 03/18/2016
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/18/2016
• Initial Report FDA Received Date: 11/10/2017
• 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: 58 YR
• Patient Weight: 80