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

Catalog Number	140.686
Medical Device Problem Code	Loss of Osseointegration (2408)
Health Effect - Clinical Codes	Pain (1994); Tissue Damage (2104)
Date of Event	04/01/2019
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Missing lot information was requested from the initial reporter.A follow up report will be submitted when the information becomes available.Exemption number: e2015015.Instradent usa, inc is submitting the report on behalf of neodent - jjgc.
Event or Problem Description
The clinician reported that 11 months after the dental implant was placed in the patient's mouth, the implant lost osseointegration in type ii bone.The clinician noted the patient's pain.The site was grafted.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.
Event or Problem Description
The clinician reported that 11 months after the dental implant was placed in ada site 10 in the patient's mouth, the implant lost osseointegration in type ii bone.The clinician noted the patient's pain.The site was grafted.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.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.The information provided in this report was based on information given by the dentist in neodent¿s products warranty form that was recorded in the system that is used by both the manufacturer and the subsidiary.The original complaint and the product were received by the subsidiary and did not arrive in the manufacturer yet.When this happens, a new evaluation of the complaint will be carried out and, if necessary, a new follow-up report will be send.
Event or Problem Description
The clinician reported that 11 months after the dental implant was placed in ada site 10 in the patient's mouth, the implant lost osseointegration in type ii bone.The clinician noted the patient's pain.The site was grafted.The product will be forwarded to the manufacturer for investigation.There were no reported post-operative complications.

• Brand Name: CM DRIVE ACQUA IMPLANT 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: 8537739
• Report Number: 3008261720-2019-01661
• Device Sequence Number: 18922618
• Product Code: DZE
• UDI-Device Identifier: 07899878016878
• UDI-Public: 07899878016878
• Combination Product (Y/N): N
• Initial Reporter State: CA
• 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: 2019
• Reporter Type: Manufacturer
• Report Source: distributor,foreign
• Initial Reporter Occupation: Dentist
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 05/09/2019
• Report Date (Section F): 04/08/2019

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: 08/16/2019
• Device Catalogue Number: 140.686
• Device Lot Number: 800314545I
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 07/09/2019
• Device Age: 1 MO
• Event Location: Other
• Date Report to Manufacturer: 04/08/2019
• Initial Date Received by Manufacturer: 04/08/2019
• Supplement Date Received by Manufacturer: 04/29/2019; 06/21/2019
• Initial Report FDA Received Date: 04/22/2019
• Supplement Report FDA Received Date: 05/09/2019; 07/09/2019
• 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: BONE GRAFT, ABUTMENT PLACEMENT; BONE GRAFT, ABUTMENT PLACEMENT; BONE GRAFT, ABUTMENT PLACEMENT; BONE GRAFT, ABUTMENT PLACEMENT
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 58 YR
• Patient Weight: 81