MAUDE Adverse Event Report: NEODENT - JJGC S.A. DRIVE SMART IMPLANT (4.3)4.3X11.5; ENDOSSEOUS DENTAL IMPLANT

Catalog Number	109.793
Medical Device Problem Code	Loss of Osseointegration (2408)
Health Effect - Clinical Codes	Swelling (2091); Tissue Damage (2104)
Date of Event	02/01/2016
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Exemption number: e2015015.Instradent usa, inc is submitting the report on behalf of neodent - jjgc.
Event or Problem Description
(b)(4).The dentist reported that 2 years after the dental implant was installed in intraoral region #7, it was verified its loss of osseointegration.Immediate load was not performed.The patient presented bone type ii.

• Brand Name: DRIVE SMART IMPLANT (4.3)4.3X11.5
• 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: 7018875
• Report Number: 3008261720-2017-02324
• Device Sequence Number: 19180842
• Product Code: DZE
• UDI-Device Identifier: 07899878000020
• UDI-Public: 07899878000020
• 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: 2014
• 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): 06/21/2016
• Report Date (Section F): 06/21/2016

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: 12/08/2018
• Device Catalogue Number: 109.793
• Device Lot Number: 800112724
• Other Device ID Number: 07899878000020
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 06/21/2016
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 11/10/2017
• Device Age: 26 MO
• Event Location: Other
• Date Report to Manufacturer: 06/21/2016
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 06/21/2016
• 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: 93