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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: NEODENT - JJGC S.A. CM TITAMAX EX IMPLANT 4.0X17; ENDOSSEOUS DENTAL IMPLANT
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NEODENT - JJGC S.A. CM TITAMAX EX IMPLANT 4.0X17; ENDOSSEOUS DENTAL IMPLANT Back to Search Results
Catalog Number 109640
Medical Device Problem Code Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code Tissue Damage (2104)
Date of Event 03/06/2015
Type of Reportable Event Serious Injury
Additional Manufacturer Narrative
Exemption number: e2015015.
 
Event or Problem Description
(b)(4) - the dentist reported that he had to removed the dental implant during its installation surgery because its lack of primary stability.No further information was provided.
 
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Brand Name
CM TITAMAX EX IMPLANT 4.0X17
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 Key7027393
Report Number3008261720-2017-01274
Device Sequence Number1275684
Product Code DZE
UDI-Device Identifier07898237568881
UDI-Public07898237568881
Combination Product (Y/N)N
Initial Reporter StateMA
Initial Reporter CountryUS
PMA/510(K) Number
K101945
Number of Events Summarized1
Summary Report (Y/N)N
Device Implanted Year2015
Device Explanted Year2015
Reporter Type Manufacturer
Report Source distributor,foreign,health pr
Initial Reporter Occupation Dentist
Type of Report Initial
Report Date (Section B) 11/09/2017
Report Date (Section F) 02/15/2016
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 Date12/20/2018
Device Catalogue Number109640
Device Lot Number800106457
Other Device ID Number07898237568881
Was Device Available for Evaluation? Device Returned to Manufacturer
Date Returned to Manufacturer02/15/2016
Was the Report Sent to FDA? No
Distributor Facility Aware Date11/14/2017
Device Age15 MO
Event Location Other
Date Report to Manufacturer02/15/2016
Type of Report(Section G)Thirty-Day
Initial Date Received by Manufacturer 02/15/2016
Initial Report FDA Received Date11/14/2017
Is This a Single-Use Device that was
Reprocessed and Reused on a Patient? (Y/N)		 No
Patient Sequence Number1
Outcome Attributed to Adverse Event Required Intervention;
Patient Age73 YR
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