MAUDE Adverse Event Report: NEODENT - JJGC S.A. CM DRIVE IMPLANT, TITANIUM, 5.0X18 MM; ENDOSSEOUS DENTAL IMPLANT

Catalog Number	109.898
Medical Device Problem Code	Failure to Osseointegrate (1863)
Health Effect - Clinical Codes	Unspecified Infection (1930); Pain (1994); Tissue Damage (2104)
Date of Event	05/23/2017
Type of Reportable Event	Serious Injury
Event or Problem Description
The clinician reported that almost 3 months after the dental implant and abutment were placed in ada site 29, non-osseointegration was verified.A bone graft was performed with infuse xxs and bio-oss.Clinician noted peri-implantitis and pain.The product 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 reported that immediate implant and immediate load were performed.
Event or Problem Description
The clinician reported that almost 3 months after the dental implant and abutment were placed in ada site 29, non-osseointegration was verified.A bone graft was performed with infuse xxs and bio-oss.Clinician noted peri-implantitis and pain.The product will be forwarded to the manufacturer for investigation.There were no reported post-operative complications.

• Brand Name: CM DRIVE IMPLANT, TITANIUM, 5.0X18 MM
• 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: 7142197
• Report Number: 3008261720-2017-06819
• Device Sequence Number: 1013793
• Product Code: DZE
• UDI-Device Identifier: 07899878001065
• UDI-Public: 07899878001065
• Combination Product (Y/N): N
• Initial Reporter State: TX
• 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: foreign
• Initial Reporter Occupation: Dental Assistant
• Type of Report: Initial,Followup
• Report Date (Section B): 12/22/2017
• Report Date (Section F): 12/05/2017

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: 04/11/2020
• Device Catalogue Number: 109.898
• Device Lot Number: 800186678I
• Other Device ID Number: 07899878001065
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 04/11/2018
• Device Age: 2 MO
• Event Location: Other
• Date Report to Manufacturer: 12/05/2017
• Initial Date Received by Manufacturer: 12/05/2017
• Supplement Date Received by Manufacturer: 03/22/2018
• Initial Report FDA Received Date: 12/22/2017
• 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
• 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: 69 YR