MAUDE Adverse Event Report: NEODENT - JJGC S.A. CM DRIVE ACQUA IMPLANT 5.0X16; ENDOSSEOUS DENTAL IMPLANT

Catalog Number	140.687
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Tissue Damage (2104)
Date of Event	07/17/2018
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Missing lot information has been requested from the complainant.A follow up report will be submitted if the information becomes available exemption number: e2015015.Instradent usa, inc is submitting the report on behalf of neodent - jjgc.
Event or Problem Description
On the day the implant was placed in ada site 19 in the mouth, there was insufficient bone quality/quality.Another implant was not placed in the same site on the same day.The site was grafted.The product will be forwarded to the manufacturer for investigation.There were no reported complications.
Additional Manufacturer Narrative
Missing lot information has been requested from the complainant.A follow up report will be submitted if the information becomes available exemption number: e2015015.Instradent usa, inc is submitting the report on behalf of neodent - jjgc.
Event or Problem Description
On the day the implant was placed in ada site 19 in the mouth, there was insufficient bone quality/quality.Another implant was not placed in the same site on the same day.The site was grafted.The product will be forwarded to the manufacturer for investigation.There were no reported complications.(b)(4).

• Brand Name: CM DRIVE ACQUA IMPLANT 5.0X16
• 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: 7830332
• Report Number: 3008261720-2018-03881
• Device Sequence Number: 14040368
• Product Code: DZE
• UDI-Device Identifier: 07899878016885
• UDI-Public: 07899878016885
• Combination Product (Y/N): N
• Initial Reporter State: UT
• Initial Reporter Country: US
• PMA/510(K) Number: K133592
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2018
• Device Explanted Year: 2018
• Reporter Type: Manufacturer
• Report Source: distributor,foreign
• Initial Reporter Occupation: Dentist
• Type of Report: Initial,Followup
• Report Date (Section B): 08/29/2018
• Report Date (Section F): 07/23/2018

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: Health Professional
• Device Catalogue Number: 140.687
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 12/04/2018
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 12/20/2018
• Event Location: Other
• Date Report to Manufacturer: 07/23/2018
• Initial Date Received by Manufacturer: 07/23/2018
• Supplement Date Received by Manufacturer: 12/04/2018
• Initial Report FDA Received Date: 08/29/2018
• Supplement Report FDA Received Date: 12/20/2018
• 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: GRAFT; GRAFT
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 51 YR