MAUDE Adverse Event Report: NEODENT - JJGC S.A. FACILITY ACQUA IMPLANT 14; ENDOSSEOUS DENTAL IMPLANT

Catalog Number	140.739
Medical Device Problem Code	Failure to Osseointegrate (1863)
Health Effect - Clinical Code	Tissue Damage (2104)
Date of Event	05/14/2019
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
The clinician reported that over 3 months after the immediate dental implant was placed in ada site 23 in the patient's mouth, the implant did not achieve osseointegration in type ii bone.The implant was lost at the time of the final impression.The clinician torqued the implant to 30 ncm.The product will be forwarded to the manufacturer for investigation.There were no reported patient complications.
Additional Manufacturer Narrative
Exemption number: e2015015.Instradent usa, inc is submitting the report on behalf of neodent - jjgc.The information provided in this report was based on information givenby 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 over 3 months after the immediate dental implant was placed in ada site 23 in the patient's mouth, the implant did not achieve osseointegration in type ii bone.The implant was lost at the time of the final impression.The clinician torqued the implant to 30 ncm.The product will be forwarded to the manufacturer for investigation.There were no reported patient complications.

• Brand Name: FACILITY ACQUA IMPLANT 14
• 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: 8681254
• Report Number: 3008261720-2019-02577
• Device Sequence Number: 16608824
• Product Code: DZE
• UDI-Device Identifier: 07899878017059
• UDI-Public: 07899878017059
• Combination Product (Y/N): N
• Initial Reporter State: OH
• Initial Reporter Country: US
• PMA/510(K) Number: K150199
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2019
• Device Explanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: distributor,foreign
• Initial Reporter Occupation: Dentist
• Type of Report: Initial,Followup
• Report Date (Section B): 06/08/2019
• Report Date (Section F): 05/23/2019

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: 01/20/2020
• Device Catalogue Number: 140.739
• Device Lot Number: 130947
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 07/15/2019
• Device Age: 1 MO
• Event Location: Other
• Date Report to Manufacturer: 05/23/2019
• Initial Date Received by Manufacturer: 05/23/2019
• Supplement Date Received by Manufacturer: 06/21/2019
• Initial Report FDA Received Date: 06/08/2019
• Supplement Report FDA Received Date: 07/15/2019
• 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: ABUTMENT PLACEMENT; ABUTMENT PLACEMENT
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Weight: 73