MAUDE Adverse Event Report: NEODENT - JJGC S.A. CM DRIVE ACQUA IMPLANT, TITANIUM, 4.3X18; ENDOSSEOUS DENTAL IMPLANT

Catalog Number	140.897
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Tissue Damage (2104)
Date of Event	10/04/2017
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
After an immediate extraction of the tooth in ada site 4, the clinician reports the implant and abutment failed upon insertion due to low torque.Clinician reports the patient bit down on block and fractured front wall.A bone graft was performed in type iii bone.The implant will be forwarded to the manufacturer for investigation.There were no reported post-operative complications.
Additional Manufacturer Narrative
Exemption number: e2015015.Instradent usa, inc is submitting the report on behalf of neodent - jjgc.The dentist used the immediate implant procedure.It suggests that the implant was anchored only in the apical part, leading to an insufficient contact between bone and implant.As a result, adequate primary stability could not be achieved.
Event or Problem Description
After an immediate extraction of the tooth in ada site 4, the clinician reports the implant and abutment failed upon insertion due to low torque.Clinician reports the patient bit down on block and fractured front wall.A bone graft was performed in type iii bone.The implant will be forwarded to the manufacturer for investigation.There were no reported post-operative complications.(b)(4).

• Brand Name: CM DRIVE ACQUA IMPLANT, TITANIUM, 4.3X18
• 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: 7100447
• Report Number: 3008261720-2017-06710
• Device Sequence Number: 1272580
• Product Code: DZE
• UDI-Device Identifier: 07899878018070
• UDI-Public: 07899878018070
• Combination Product (Y/N): N
• Initial Reporter State: MO
• Initial Reporter Country: US
• PMA/510(K) Number: K150182
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2017
• Device Explanted Year: 2017
• Reporter Type: Manufacturer
• Report Source: distributor,foreign
• Initial Reporter Occupation: Dental Assistant
• Type of Report: Initial,Followup
• Report Date (Section B): 12/08/2017
• Report Date (Section F): 11/14/2017

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: 06/07/2019
• Device Catalogue Number: 140.897
• Device Lot Number: 800304026I
• Other Device ID Number: 07899878018070
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 04/04/2018
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 04/25/2018
• Device Age: 1 MO
• Event Location: Other
• Date Report to Manufacturer: 11/14/2017
• Initial Date Received by Manufacturer: 11/14/2017
• Supplement Date Received by Manufacturer: 04/04/2018
• Initial Report FDA Received Date: 12/08/2017
• Supplement Report FDA Received Date: 04/25/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: ABUTMENT, BONE GRAFT; ABUTMENT, BONE GRAFT; ABUTMENT, BONE GRAFT
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 42 YR