MAUDE Adverse Event Report: NEODENT - JJGC S.A. CM ALVIM ACQUA IMPL TI 5.0X13; ENDOSSEOUS DENTAL IMPLANT

Catalog Number	140.655
Medical Device Problem Code	Difficult to Remove (1528)
Health Effect - Clinical Code	Tissue Damage (2104)
Date of Event	08/28/2017
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
The clinician reported when implant was placed in ada site 14 of the patient's mouth, a local infection was present.A bone graft was executed on type iii bone.Primary stability was not obtained and mobility was present.The device will be forwarded to the manufacturer for investigation.There were no reported patient injuries or operative (or post-operative) complications.
Additional Manufacturer Narrative
Exemption number: e2015015.Instradent usa, inc is submitting the report on behalf of neodent - jjgc.In telephone contact, the dentist informed that he did not have information about lot number of the product.
Event or Problem Description
The clinician reported when implant was placed in ada site 14 of the patient's mouth, a local infection was present.A bone graft was executed on type iii bone.Primary stability was not obtained and mobility was present.The device will be forwarded to the manufacturer for investigation.There were no reported patient injuries or operative (or post-operative)complications.(b)(4).

• Brand Name: CM ALVIM ACQUA IMPL TI 5.0X13
• 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: 7029696
• Report Number: 3008261720-2017-04975
• Device Sequence Number: 19155538
• Product Code: DZE
• UDI-Device Identifier: 07899878016670
• UDI-Public: 07899878016670
• Combination Product (Y/N): N
• Initial Reporter State: UT
• Initial Reporter Country: US
• PMA/510(K) Number: K150199
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2017
• Device Explanted Year: 2017
• Reporter Type: Manufacturer
• Report Source: foreign
• Initial Reporter Occupation: Dentist
• Type of Report: Initial,Followup
• Report Date (Section B): 11/14/2017
• Report Date (Section F): 09/05/2017

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: 06/26/2018
• Device Catalogue Number: 140.655
• Device Lot Number: 60745
• Other Device ID Number: 07899878016670
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 04/11/2018
• Device Age: 1 MO
• Event Location: Other
• Date Report to Manufacturer: 09/05/2017
• Initial Date Received by Manufacturer: 09/05/2017
• Supplement Date Received by Manufacturer: 01/30/2018
• Initial Report FDA Received Date: 11/14/2017
• Supplement Report FDA Received Date: 04/11/2018
• 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: 66 YR