MAUDE Adverse Event Report: NEODENT - JJGC S.A. CM DRIVE ACQUA IMPLANT 5.0X16 MM; 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	11/19/2018
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Exemption number: e2015015.Instradent usa, inc is submitting the report on behalf of neodent - jjgc.Considering the surgical methodology, it was seen that the dentist has selected an implant design which is not recommended for the patient's bone quality.Moreover, the dentist installed the dental implant after its expiration date.
Event or Problem Description
(b)(4) ¿ the dentist reported that had to remove dental implant during its installation surgery because it did not achieve a good primary stability.Moreover, the patient presented bone type ii.

• Brand Name: CM DRIVE ACQUA IMPLANT 5.0X16 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: 8354989
• Report Number: 3008261720-2019-00762
• Device Sequence Number: 14004053
• Product Code: DZE
• UDI-Device Identifier: 07899878016885
• UDI-Public: 07899878016885
• Combination Product (Y/N): N
• Initial Reporter Country: CH
• 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,health pr
• Initial Reporter Occupation: Dentist
• Type of Report: Initial
• Report Date (Section B): 02/20/2019
• Report Date (Section F): 01/31/2019

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 Expiration Date: 08/10/2017
• Device Catalogue Number: 140.687
• Device Lot Number: 800204455I
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 01/31/2019
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 02/20/2019
• Device Age: 39 MO
• Event Location: Other
• Date Report to Manufacturer: 01/31/2019
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 01/31/2019
• Initial Report FDA Received Date: 02/20/2019
• 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