Bones, Paws, and Pixels: The 3D Revolution in Vet Medicine (Virtual Event Recording)

Learn how 3D printing technology is revolutionizing veterinary medicine with applications from orthopedic correction guides to custom-made titanium implants for cancer patients.

• 3D printing allows unprecedented precision in complex veterinary surgeries
• Orthopedic surgical guides can correct deformities within two degrees of accuracy
• Custom implants enable limb-sparing procedures for bone cancer patients
• Neurosurgical applications make pedicle screw placement safer for spinal fixation
• Maxillofacial reconstruction with 3D printed implants offers solutions for trauma and cancer cases
• Manufacturing standards remain a concern as veterinary implants lack human-grade regulations
• Technology has evolved from simple models to complex guide systems in less than a decade
• Educational models with bone-like properties are enhancing surgical training
• Proper CT imaging techniques are crucial for successful 3D model creation
• Collaboration between surgeons and engineers produces the best outcomes

Join us on this journey through cutting-edge veterinary medicine and see how this technology could benefit your practice or pet.

Full video recording is now available at 3DHEALS.COM/Courses

Chapters

• 0:00 Introduction to 3D Heals and Webinar Overview
• 3:20 Mimics Impact in Veterinary Medicine
• 6:50 Use Cases and Applications of 3D Technology
• 10:00 Orthopedic Surgery Planning with Mimics
• 19:37 Case Studies by Vet3D and Surgical Planning
• 29:02 Maxillofacial Reconstruction and AR Applications
• 43:40 Cabiomeda's Approach to Veterinary Implants
• 55:12 Quality Standards and Manufacturing Challenges
• 1:04:50 VMix and Complex Surgical Cases
• 1:27:40 Imaging Considerations for 3D Printing
• 1:45:00 Panel Discussion on Future of the Industry
• 1:53:58 Education and Training for Next Generation

Transcript

Speaker 1: 0:03

Fantastic. Good morning. Rise and shine everybody. Okay, we have some audience slowly trickling in now. Okay, my name is Jenny Chen. I'm just going to use the first couple of minutes, when people are slowly getting into the webinar, to introduce myself and 3D Heels. My name is Jenny Chen. I started 3D Heels about actually apparently 10 years ago. I can't believe it. I'm a steel practicing radiologist and I got into 3D printing because you know anatomical mottos to get started with and actually the first software I encountered probably is Materialize.

Speaker 1: 0:44

Who's also the sponsor for this event today? And our goal we have three. One is to educate everyone about 3D printing. I think it's extremely important because people, if you meet anybody in the street and ask them what do you think 3D printing can do for healthcare, I bet what they think is enable 3D hand and that's all they can think about, even though the applications are so wide and deeply penetrating in all verticals in healthcare. So I think it's important for us to educate everyone about the potential and existing practice using 3D printing in healthcare.

Speaker 1: 1:21

Now, and number two is networking. So, even though everyone on the webinar today is from all over the world and typically we have 30, 40 countries, in terms of audience mix. The majority is from North America, a lot from Canada and India, so it's a very international crowd. So we're hoping people can meet one another and maybe start interesting conversations and even companies. And number three is we have a program called Pitch3D where we discover early stage, from seed to series, a early stage startup in the space of 3D technologies. So it's not just 3D printing but any related technologies like AR, vr, which I'm pretty sure a lot of people here also use on occasions. So those are the three functionalities 3D Heels perform at the moment, and this topic is super interesting to both me personally, because I actually own a dog the dog behind me is not my real dog but very similar to my dog and I become a pet owner three years ago and learned so much about veterinarian medicine than I ever, and I realized that veterinarian medicine is not just human medicine transforming to animals.

Speaker 1: 2:42

It's a completely different, really different species, and so this topic is very interesting to me personally. But I also realize the vast potential that 3D printing can play in this space and I'm sure our amazing panel today will share with us where things are and how it can transform the industry. So, without further ado, I'd like to introduce our first speaker, bradley Thomas, who is basically leading the effort of animal care in Materialize. Materialize is also our sponsor, so I really appreciate the support. Brad, why don't you take over?

Speaker 2: 3:23

Thank you, Jenny.

Speaker 3: 3:28

All righty.

Speaker 2: 3:39

All righty. So, first off, I'm Brad Tumas account manager of academics. I also get the pleasure of working with vet hospitals at university as well as private institutions. So this is Mimics Impact in Veterinary Medicine. So first off, I wanted to start off by just info sharing. So we attended VOS this last month in Colorado and here are some key learnings.

Speaker 2: 4:09

So many surgeons are interested in virtual surgical planning and 3D printing, if they're not already doing it. Many residents are actually conducting research around patient specific virtual surgical planning and 3D printing. Orthopedic surgical guides are the primary clinical use case for surgeons. Guide, our guide design tool, updates and mimics uh latest release, have greatly reduced creation time. Uh, the orthopedic community is is awesome. They're very collaborative. I always enjoy going to the, to the shows, to the acvs, vos, all these different things, and just seeing the dynamics of everyone working together and knowing each other and really working really well together. There's no um, there's no, you know, high competitiveness. It's. It's really just really collaborative. There is a high demand um currently for surgeons, whether it be in mobile surgery or in new institutional locations, and I had never even heard of mobile surgery. I thought that was very interesting, just uh interesting, just going from practice to practice.

Speaker 2: 5:08

So what are the use cases of 3D visualization? A lot of times, education and training, surgical rehearsal, surgical planning, 3d printed implants and parts, plate pre-contouring, 3d printed recovery sleeves, and then external prosthetics and orthotics are another use case. So where do we fit in? What is Mimix? So Mimix is image processing and anatomical design software. So what we do is we are able to take the DICOM imaging, ct, mri, ultrasound and bring it to your PC and create a 3D model. Rendering from that so mixed platform is something that we want to see. An end-to-end use case where you're going from end-to-end. You have everything almost covered within our software. We have affordable package solutions for every size institution. We're looking to give you a return on your investment for a seamless end-to-end solution, starting from image acquisition. That's starting off with your segmentation, what I showed in the previous slide, creating your initial mask and making a model, and then there's all sorts of outputs, whether that's just being 3D model, measuring, planning, designing, and if your end goal is to 3D print and finally get personalized treatment. That's typically the end goal we see in hospital as well as in veterinary medicine. So what are some of our applications?

Speaker 2: 6:41

Orthopedic surgery, as I mentioned mentioned, there's um, as listed here, several different um surgeries that are orthopedic, uh type surgeries that are used uh within mimics, uh or use mimics is used to to plan these surgeries, uh, these models. Here are some reduction guides and um placement guides for uh ingo the deformity. This is a case that we worked on several years ago for another conference with Dr Jason Bleedhorn and Dr Carlin, and then this is just a quick rendering of the STLs just to show you in 3D, and so these are patient-specific guides based on the anatomy. And, moving to this, this is just a quick video. So what we're doing here is this angular limb deformity, initial segmentation, creating a mask and cropping and splitting the anatomy interest from the surrounding that we're not so interested in, and so this is just simple cleanup for some of those hounsfield units that are are kind of overlapping, and just cleaning up the model to make sure it's a nice smooth model. So here we're going ahead and we're wrapping the model and making it a nice smooth model, while still keeping the anatomical accuracy, and then marking the model in order to then create sorry, then create a cylinder down the center of the shaft, of the femoral shaft, and then creating another anatomical landmark with the head and using our design tools here to do so.

Speaker 2: 8:57

And so this is creating another plane based on the anatomy in order to create the cut right angle of the reduction guide, to create the correct cutting service, in order to create the right angle of the reduction guide, to create the correct cutting service, in order to properly make the cutting guide and have those planes in the correct anatomical area in order to make the correction. And so here now we have the cut femur and we're now placing it into position to then create the reposition guide for after the osteotomy is done. And so here again you'll see us create the area where we want the guide base to be created, and then we're going to use some of our quick design tools, so creating a guide base to be created. And then we're gonna use some of our quick design tools so creating a guide base. I know it's sped up, but it can very quickly be done. We have a guiding tube, a cut slot, a flange and a guide bridge that can just quickly be added. And then that was just a quick check to make sure that the 3D model was good for 3D printing. And so, based on on those angles that we created, uh, with the um, based on those angles we created. We now create a flange to line up with those that angle and now creating the the cylinders for the guide tubes and for pin placement. So here now we have our guide tubes and we've took out the inner cylinder and we now have our guide tube created. This is a simple cleanup of the triangles just to make sure that it's okay for 3D printing, and now cleaning up the guide base in order to have it fit snugly on the femur in surgery. And this is another one of those quick tools that I mentioned, the guide base tool, where we're quickly creating those connections. And so that's our final outcome. And okay, just give me one second. There we go.

Speaker 2: 12:27

So, moving on, another example case in ortho. So this is pre-operative planning for hip acetabular cup placement. There's 3D measurements taken of the ALO version and angle of inclination to lead to better cup orientation. There are four different patients with different types of variations. So there's luxoid acetabulum, chronic dysplasia, trauma, acetabular deformation. Patient-specific guides were created to have pin placement secured to the ileal body. This prevented post-op luxation just by getting the correct cup placement.

Speaker 2: 13:03

So here is the final model. So this is a very complex model and a very interesting use case, but I wanted to share a different. So other applications include dental and CMF surgeries, oncology and tumor resection. This is a model from Michigan State. A 16-year-old female spayed domestic short hair cat. Michigan State. A 16-year-old female spayed domestic short hair cat. 10-month history of behavior changes led to a visit to the hospital and MRI. Surgical trainees utilized the model to plan the surgical approach. The craniotomy sterilized and brought into surgery to help visualize interop and post-op imaging.

Speaker 2: 13:41

Confirmed complete excision of the tumor. And another simple case here is the canine root surface area. This can be used either for diagnosis or for just verifying canine phenotype. This was done by Dr Ashley Capon-Kerns at Animal Dental Center. Moving on to more of a complex case, this was Dr Jason Suka, dr Elias Wolfs and Dr Thatcher at University of Wisconsin-Madison.

Speaker 2: 14:15

So this is a orbital reconstruction and a titanium mesh implant excision of the orbitozyygomatic maxillary tumor. There were three different patients. We're looking here at the Maltese patient. So what was first done was a CT scan of the patient, mirroring of the healthy orbit to the affected site, 3d printing of the skull with the mirrored OZMC seed, adaption of customized titanium mesh, surgical excision of the lesion and direct or staged insert insertion of the implant. So figure A is your post cyst removal and tooth removal. Figure B is the progression of the lesion after. Figure C is post op titanium mesh implanted and lesion extracted. And then figure d is eight months post-op with no, no sign of that lesion, uh reoccurrence. So one quote I have from this group these techniques provide the surgeon with improved visualization and thus better understanding of the 3d printing anatomy. Its virtual surgical planning is feasible in a clinical setting and may decrease surgical time and increase surgical accuracy. This allows improved fidelity of the surgically repaired side and although it might have took an hour or two to plan this, it saved time intraoperatively and increased the anatomic fidelity.

Speaker 2: 15:50

One more application here. So neurology and spinal surgery. You know vertebral pedicle screws, spinal fractures, prosthetics and limb reconstruction. Then congenital heart defect is one that we've seen. That's new and we're excited that we were able to use it within MIMICS.

Speaker 2: 16:07

So this case here is a dog was presented with obstructive shock, high heart rate, weak femoral arterial pulses. It had an atrial septal defect and typically this isn't diagnosed until about two years into adulthood, and this is about two years into the, the into adulthood, and this is about two years into a dog and actually in the human side it's about 20 to four years old. Until you see this defect, ct imaging and three modeling was used to decide the appropriate treatment of the dog in this case, and no procedure was done in this dog, but the congenital heart disease was managed for more than two years without reoccurrence of heart failure. So they were able to assess and figure out if there was it was worth it to do this surgery. Any questions? And here's all my contact information and also a QR code for my LinkedIn If you want to connect and be happy to talk to y'all.

Speaker 1: 17:04

Thank you, brad, for a very comprehensive presentation. Looks like you're going into every single medical field, you know. My question as a practitioner is you know, even though you said that making these designs are fairly straightforward to a person who's outside of engineering, who have limited skills, I wonder if you have any ways to automate this process or script or something that make it easier for people like me?

Speaker 2: 17:33

Yeah, so we do have comprehensive trainings as well. We have a full support team to assist with any developments and workflows. But we also have scripting within our software and we're currently working on a script for the angular limb design design workflow, because that's a very common one, we see, and we had many requests at VOS like hey, if you guys made a script of that, it'd be something we'd be interested. So we're we're looking to develop more scripts. We do have a, a scripting package that has some additional scripts that can be used for, you know, different various anatomical sites, but right now there's nothing for VET. But we're actually developing it right now.

Speaker 1: 18:11

Okay, and also I remember last year I think I forgot the name of the presenter but also from Materialize, talking about they use population data to generate AI, ML algorithms to make the design process even easier. I don't know if that's even possible for veterinarian practices. I mean, do you guys have any kind of AI or ML kind of functionality?

Speaker 2: 18:36

Yeah, so we have AI segmentation and actually we're testing and it seems to be working with a lot of the veterinary bones is we have AI segmentation that's built into our software and you can directly request it and it goes into the cloud and it's done typically less than 15 minutes and it works with animal anatomy as well. So the human anatomy AI segmentations are actually working for animal anatomy as well.

Speaker 1: 19:05

Human anatomy. Ai segmentations are actually working for animal anatomy as well. And what's?

Speaker 2: 19:17

the typical learning curve, time-wise, for a veterinarian doctor to learn and really pick up and incorporate into their practices? Yeah, that's a good question. So it depends on really the motivation of said surgeon and the time they have. I have a couple of cases where people have picked it up in late November and in a month they were creating their own guides. Yes, it might have taken a little bit of time because they haven't completely figured out their workflow, but I just touched base with him before VOS and he's like I brought my workflow down to less than an hour. So from you know, initially four hours trying to figure out his workflow to now less than an hour, and we can even work with him to improve that, I think.

Speaker 2: 19:56

I think there's definitely a. I would say our software is user friendly but there's also a slight learning curve. I would say our software is user friendly but there's also a slight learning curve. And I'll say for that angular limb deformity case that I showed that was our application engineer's first time going through the workflow and I gave him instructions on how to do it. It was his first time doing it and he did that whole workflow in 30 minutes. Obviously it was sped up to fit this form, fit this, uh, this forum. But, um, it took them maybe four to six hours to really get a good feel and really get get a understanding of that workflow, great.

Speaker 1: 20:33

Well, thank you very much for the presentation. Again, we'll come back for the panelists discussion. Um, I'm actually going to mix things up a little bit, because I just realized we have quite a few clinicians uh on on this webinar and I want to kind of like mix it up a little bit. So I'm going to actually move Bill, dr Bill Oxley, up to the next presenter. I met Bill many years ago and he is not only a practitioner but also founded a couple companies, including one called Vet3D, and so, bill, I'll let you take over, including one called VET3D.

Speaker 6: 21:07

And so, bill, I'll let you take over, thank you. Thank you, jenny, and thanks, brad, for that presentation. Let me see if I can share my screen here. Are you guys seeing that? Okay, yeah, perfect, fantastic, okay. So, um, I guess, I guess it's good to follow on from that, actually, because I guess I can give the other view of this.

Speaker 6: 21:59

As an orthopod, as a clinician, my take on how we use the whole technology that Brad has described is, I guess, coming at it from the, the other perspective, I suppose. So, of a briefly um, to describe who I am um, I'm a vet, obviously. Um, I graduated in 1997 and I worked in general practice for some years before taking a sort of specialist route really very much focused on orthopaedics, and this was something that I guess I'd always been passionate about. But, following on from doing a residency at Willows, I then became an RCVS specialist and basically did full-time referral orthopedics for maybe 10 years, and during that time, I kind of became aware of the potential of 3D printing initially, and then surgical guide systems, and this was really the motivation for me starting Vet3D in 2014, when I just started doing cases for myself. Maybe, maybe, I guess five years later I was doing so many cases that I didn't have time to do both. So since then, I've been running VET3D full time and I guess I'm going to take you on a very quick journey.

Speaker 6: 23:21

This was, I suppose, where I very first started back in 2014. This was the first case I ever used 3D printing, for this was a little pug called Pixie who had a pretty nasty fracture of her humerus, and I just got my first FDM printer, which produced beautiful green bones, as you can see, and I thought it would be kind of neat to print the opposite humus, to draw on the the fracture lines and then to pre-contour the plates. So, um, I was able to use the model to pre-contour the plates that I thought I might want to use to fix the surgery, to fix the fracture, and this was a pixie the next day. It was pretty cool and I guess that was the very first time I ever used 3D printing. Obviously, as Brad showed, I mean on a very, very simplistic level, in order to take your 3D models from your CT to the printer, you have to take them pretty much through some kind of CAD, uh software, and when I was doing this, I realized the potential for creating guides, and this was the very first uh system that we ever made. I mean, the, the thing that's labeled C, that is actually a surgical guide. I mean, you wouldn't believe how things have changed since then, but that was the first clinical guide that we ever used, and I'm pretty sure that was the first time that clinical guides had ever been used in veterinary medicine or neurosurgery, and this was the paper that we published with my colleague, seb Bayer, who still works with me at Vet3D, and this was certainly the first veterinary publication of a clinically used 3d printed guide, and we use this for, obviously, a pedicle screw placement in a neurosurgical setting. Um, and this was the next evolution um, this was an arthrodesis guide. That um I basically created myself back in 2017, and this was again the first description of a, an osteotomy and reduction guide system, and this still forms the basis of what we do now, although things have obviously moved on a long way.

Speaker 6: 25:32

Um, over time, we were able to publish more and more, and we've published a lot of papers now describing all sorts of facets of surgical guide creation, deformity assessment, surgical planning guide, design guide, application guide, accuracy and this was the first paper we published that really showed pretty good accuracy. These are reasonably primitive guides. I mean. You can see in the image, these are guides that I designed, really nothing like what my CAD engineers design these days. These were very, very primitive. But even with these really pretty, pretty primitive guides, this is what six, six years ago now, seven years ago, we were able to demonstrate accuracy of corrections within two degrees in multiple planes, which is pretty pretty good really, and I think I think, as techniques have just moved on stratospherically since then, I think there's no question the literature demonstrates that we can correct deformities, we can plan pedicle screws with dramatic accuracy these days and, as I say, really, the osteostomy reduction guide system, the basic system, has pretty much stayed the same from those really very early days.

Speaker 6: 26:49

Um, what's changed, I suppose, is how we apply it, and brad demonstrated talk very nicely about how you know the, the processes of what is involved, but I think the, the thing that is really different with how we approach cases now is it's not so much designing the guides, building the guides you know these things are evolving so quickly it's really how we assess the case. How do we decide where to cut, how do we decide what to cut, what is the, the process of actually utilizing the, the raw ct data, to do 3d deformity assessments, so we know how to get the best outcomes from our patients. And in many ways, that's the hard part. I mean, that's the next frontier and creating the guys themselves. I wouldn't say it's the easy part, but it's uh, the, the, the, the initial planning, that is, we're just discovering, frontier after frontier, about how we actually should be assessing these deformities and planning these surgeries in 3D. Um, oh, I'm just going to show you that video there. Um, so this is, um, effectively the way that the guide systems have. Um, I suppose I'd call this a basic guide system. Now, this, this is a DFO system. This is the one that Brad showed you in 3MATIC, I think, and this is effectively the same system. This is how we do them these days. These are the guides that we use, and the osteotomy and reduction principle is the basis for, I think, all of the guide systems that we do, really, although things get a lot more complex than this. But this video just gives you an illustration about how we can utilise guides to create the planned correction that we've worked out beforehand.

Speaker 6: 28:39

And, of course, we've mentioned neurosurgical applications, pedicle screw planning. This is where we started this was our first ever system, really but the ability to plan safe pedicle screw trajectories in really small pedicles and we do these down to French Bulldog and Pug sizes, so these are 1.5 mil screws and the ability to safely plan these trajectories using the ability to see everything in cross-section, see everything in 3D, plan optimal entry points, safe exit points, safe corridors, and then to create guides that we can then utilize to place those. This has been the mainstay of oh, probably I don't know if we've done a thousand of these, but it must be something like that. We've done so many of these cases. Now we know these systems work extremely well, um, and the neurosurgical stuff is fantastically exciting. And these are these are screws that are unbelievably difficult to place without the use of guides, but also the CAD planning. I can't emphasize how important that is.

Speaker 6: 29:45

So, moving on to some maybe some more complicated stuff because I guess this is what kind of fires people up this was a dog called Rolo. This is an example of a case where we were able to use CAD planning and guides and a custom implant to do a combined correction. So not only had this poor little fella injured his carpus, you can see he's kind of had an injury and managed to disrupt the small carpal bones in his paw, but before that he's also got quite a nasty limb deformity and he'd kind of been coping okay with this limb deformity. But the carpal injury required a fusion of the joint, and fusing a joint at the bottom of a bendy leg is not so great for the patient. So we really needed to fix both problems at once and prior to the the ability to apply this technology. It would be immensely challenging to correct, uh, firstly to plan this, but then then to not only plan it get a nice straight leg but then work out how we're going to cut the bones, how we're going to do the fusion, how we're going to fix all these three bits together at the same time. But using CAD planning we're able to put all of those things together in the plan. We can create guides. Sorry about the gory pictures. I should have warned you, but I guess you guys are expecting a bit of surgery and this is an animation of how we actually utilize the guide system. So the concept differs a little bit from the DFO video I showed you before.

Speaker 6: 31:18

When we're using custom plates these days, because the plates are 3D printed. We're able to use the plate as a reduction guide. So we don't have to use those pins and the reduction guide that you saw in the previous videos. We can actually use the plate to do that. But that requires us to know exactly where those screws are going to go. So the screw trajectories are CAD planned. That integrates with the custom plate that we design and so we can plan the system around that. So we know that if we pre-drill the pilot holes for the screws, we make the cuts in the right place. We take those three segments that we've created and we put all of those back together in the CAD to achieve the plan that we were looking for. We can make the whole process very quick and very seamless for the surgeon.

Speaker 6: 32:11

And you can see the images on the left these are a colleague of mine called Christoph Stork I don't imagine he's watching, but he's a great surgeon based in the UK and this is how the custom plate goes on. And because we've already drilled those holes, we know exactly where those holes are going to be. They're going to match up with the plate that fits exactly onto the bone, and it's a very straightforward thing then for the surgeon to apply the screws, the bone segments are pulled up onto the plate and we achieve the pre-planned alignment that we're looking for. And this is Rolo afterwards. You can see the pre-planned alignment that we're looking for. Um, and this is rollo afterwards um, you can see the, the post-optic radiographs really beautifully aligned. Uh, and he had a nice straight leg and there's a.

Speaker 6: 32:53

These heal really quickly and getting these, these fusions, to heal traditionally was very difficult because they used to have the joints bird, it was very difficult to get the bone to heal. But because we're using guides and ostectomized arthrodesis tends to heal extremely well, so it's a great application for this surgery, for this technique. Another case this is a great dane, seven-year-old great dane nasty bone tumor. So this is a tumor called osteosarcoma and these are are really very aggressive. These tumours, as you can see in the radiographs, they're very destructive, they're very painful and these dogs are really quite sore and these progress quickly and if you don't catch these, these limbs will fracture and that's an extremely difficult situation to sort out. So the way that we tend to address these these days again a custom plate I mean these are not the cases we do all the time they're kind of cool, so hence why I'm presenting them here.

Speaker 6: 33:53

But this is the kind of custom implant that we can design, and the principles of this implant are similar to the previous case that I showed you. We work out which bit of bone we need to reset. We design the plate using the same principle. We know where the screws are going to be, we know where the plate's going to be, we know what shape we want the leg to be, we know which section of bone we want to take out. So we design the plate accordingly and we use guides to do the osteotomies and to drill the pilot holes for the screws. This is the plate. My engineers are absolutely amazing at creating these and these are not easy to make or design. So there's quite a lot that technical that goes into this, which I'll briefly touch on at the end. But this is the implant that we designed for this case. As you can see, there are lots of screw holes.

Speaker 6: 34:47

These have to survive a long time, and the video you'll see in a minute shows why we put so many screws into these and the cage in the middle is filled with graft. So that's the tumour, so a bit of a gory one, but you can see how horrible these tumours are. They're really, really aggressive and nasty. The graft cage is filled with with bone graft and that's then implanted. This is the post-op radiographs and this is the dog at 13 weeks. And this is probably one of my favorite ever cases, one of my favorite ever videos, because this kind of outcome is pretty much unthinkable with traditional limb spare techniques and the beauty of the system that I've described to you. It's it's hard to see and we don't really need to get into this today, but there is bone ingrowth. So this, this implant is is is ingrown um, and that will give it the longevity it needs to kind of survive being in a very boisterous great dame in the long term. But I'd mention that fat max maxillofacial um.

Speaker 6: 35:51

This is an example of a? Uh, kerry terrier that had a unfortunate episode with another dog in the park. Uh, he basically had his um, his front of his nose grabbed by a big dog, um, and you can see it's kind of pretty much disconnected here. Um, this was a failed attempt to repair that. So this poor dog not only has an unstable front of his face, front of his maxilla, but he's also lost his soft palate and you can see well, the mouse is kind of pointing there. There's a huge hole in the bone of his maxilla. But he's also lost his soft palate and you can see where the mouse is kind of pointing there. There's a huge hole in the the bone of his soft palate, so his mouth is communicating with his nose. So it's a pretty desperate situation for this dog and traditionally again, this would be a phenomenally difficult scenario to sort out.

Speaker 6: 36:40

Um, so this is materialized software, but you recognize it, and what we're doing here is using the software to plan safe trajectories for screws so again missing those teeth providing appropriate anchor points for a custom implant that we can utilize to firstly close the big defect in the hard palate, but also, at the same time, we created a further implant to stabilize the original failed stabilization on the top of the maxilla. So these are the implants that we designed. Again, getting appropriate fixation points in a in a place like this is is a very difficult sorry, excuse me, it's a very difficult thing to do. So. Uh, a nice plan and very nice implants and this was the. This has only just been done so I can't show you any follow-up, but these are literally just. I think it was done last week.

Speaker 6: 37:45

Jenny mentioned, asked me pre-op, if we pre presentation, if we do anything with AR and we do use sorry, we do use augmented reality to a limited extent. This isn't something that is routine by any means, but I'll show you one example of a case where we did use that. This was a little dog with bilateral antebrachial deformities. As you can see, one side is worse than the other. It's quite a cute little fella. On one side we were able to plan a correction with a single level, a single level osteotomy. On the other side, he needed a double level osteotomy.

Speaker 6: 38:27

And again, this is, I guess, the next, the previous dimension to everything that brad showed in the, in the, in the materialized package. It's, it's great to be able to do your segment, a segmentation to, to design your guides, to make your own guides, but the difficulty it's not so much that, it's the planning. I mean, how do you know how to, how to plan that in 3d, how to assess that deformity in 3d, where to make the osteotomies? And this is the bit that this is. What I do full time now is is basically plan these corrections and uh, it, it, it's, it's difficult and it's um, it's a complex thing and, uh, something that contributes enormously to the outcome in these cases.

Speaker 6: 39:13

So, when we use the ar, we uh partner with a company called amadisk in the uk. These, these are this was developed this technology by a human surgeon called Ad Ghanda. He's a phenomenal surgeon super guy and he helps us create the integration between our 3D modeling and the AR systems that you need to actually translate these techniques into surgery. So, again, the first step is to create an animation very much like what I showed you for the previous cases, but what Amadisc will then do is take that into the AR software and systems. They use a HoloLens and I'll show you how it looks for the surgeon. Effectively, you can see so there's a kind of a console and what the surgeon here is doing. They can use their hand gestures to move between stages of the surgery. They can see instructions for those stages listed and also the animation, the 3d animation, uh kind of projected, so that they can see what they kind of need to do next.

Speaker 6: 40:30

So, um, that was a it's brief, but you get the get the picture and I think, for for the more routine things that we do, arguably not essential, but for more, uh, complex applications like the double level corrections, the custom plate stuff, some of the neurosurgical applications. This is a wonderful tool and I think it will become a lot more uh, a lot more popular and a lot more used. And that's woody's outcome. He did really well. So just in summary, um, I think the few key things I'd like to say we've come such a long way and basically from sort of FDM printing in my back room to making these amazing custom implants in not really very long at all, and it's super exciting where we're going to go with this.

Speaker 6: 41:18

As Brad said, there's been a huge uptake um in clinical application and I think that's only going to continue. We've supplied over 3 000 clinical guide systems now and we're doing huge numbers um both of just the more basic guide systems but the more advanced custom implant systems, that that I've showed you, and these go everywhere, um, now they go all over the world and for us it's always been critical to to combine this with clinical research and we've we've published a lot of information on this that I think those two things have to go hand in hand. But these things come they don't come easy and as we do more complex things the amount of planning, 3d deformity assessment, the clinical integration of the planning and the assessment and the guide systems and what we can do and the implants becomes harder and harder and harder. And I'm incredibly lucky to have there are five of us now boarded specialists working and we mostly do consultancy. We don't five of us now board of specialists working and we mostly do consultancy. We don't the.

Speaker 6: 42:24

The guide systems are designed, uh and made by my team of cat engineers and techs and it's the. The bit that surgeons do is the bit before, it's the surgical planning, it's the assessment, the integration with what the surgeon wants for the case and what, what seems to be most appropriate, and that's the bit that's really hard, um, but yeah, it's unbelievably rewarding, but it's also really quite a challenging environment to work in and we rely, we use Materialise, we use Formlabs, we rely on a lot of engineering, software and expert support to be able to produce these systems and, as I guess I've touched on, there will be more and more use of custom plates. This is an enormously growing area. There will be area integration. In-house printing is something that will come along and reduced cost will come too, and that's the end. Thank you for listening.

Speaker 1: 43:19

Thank you so much, bill. I agree, looks like there has been a lot of progress, um, and the cases are amazing. What do you think in terms you said that the uh, some of the surgical guide were the simpler version now is more complex? What are some of the major advancements in terms of the design concept for the surgical guides?

Speaker 6: 43:43

I think it comes back to the. That's a great question actually. It comes back to the complexity of the planning which I kind of mentioned a couple of times. I think the concept where we kind of started off nearly 10 years ago with a single level cut, an osteotomy guide that goes on, then you make your cuts and then a reduction guide goes on, that's a nice simple, straightforward system and that's still the basis of what we do.

Speaker 6: 44:08

But from there to now we've realised just the vast greater potential of what we can achieve with these systems and I think the understanding of some of the cases I've shown you the double level corrections, the integration of the custom implants these have been driven by clinical need but they've also required a significant evolution in how we design the guides themselves. The guides have had to get more complex and the integration with the custom plates has had to get more complex to service that clinical need. So I think that's where it's been driven from has had to get more complex to service that clinical need. So I think that's where it's been driven from. But we've certainly used more and more advanced softwares to be able to achieve that for surgeons and we use a whole range, including Materialise in order to produce that sort of range of things that are needed for these clinical situations.

Speaker 1: 45:01

Sounds like the veterinarian clinicians are also evolving with the technology.

Speaker 6: 45:06

Enormously, and these are new techniques and a lot of what? Well, a lot much of what we do is saying to surgeons look, you know, here's a concept completely foreign to anything you've seen before. You know, the use of these custom plates as reduction devices. This isn't. Nobody gets taught this at vet school. You know a lot of people don't get taught this in residency. So you know, it is a very much a collaborative process of um really educating surgeons how to use these systems, um, as well as actually creating them. So, yeah, it's exciting, but it's kind of hard work to be able to do that as well.

Speaker 1: 45:47

Great. We have two questions from the audience that I'll address really quickly. One is from Ernest Kostinko. He wants to do an internship at your clinic. So, ernest, you should just email Bill directly to see if there's a fit. We will. I think we share all the contacts already. So, ernest, you should just email Bill directly to see if there's a fit. We will. I think we share all the contacts already. And then the other question is very technical. It says are the implant holes DCP or no need from Sebastian? I guess DCP is a dynamic compression plate. I actually look it up.

Speaker 6: 46:23

No idea what that does, but other than the, you know the words, words. So there's a couple of aspects, I think, to that question and sebastian correct me if I'm wrong the, the first, the, the, the likely, the use of a dcp hole allows for compression of an osteotomy um, and I think that's maybe where the question is focused. Another aspect to that is locking holes, and again this is another whole lecture really, but whether we should be using locking screw technology in these custom plates and the questions are linked. I think the answer is we can design these to create compression, but the truth is we don't really need to and, um, it's probably, it's not it, this is really technical and there's a big. I could talk about this for ages and it's boring, uh. But yeah, the answer to the question is we can design those, but we basically we don't really need to and I'm very happy to expand on that, but it's probably not the the time or place to do that.

Speaker 1: 47:24

Yes, we are pressed on time yes, well, thank you, bill.

Speaker 1: 47:28

I mean I'm sure you can talk, uh, outside of this event, um, so we're going to move on to our next because we, like bill said, we're pressed on time. We need to move on. Um, thank you so much for a fantastic presentation, but I learned so much every time you present and we'll come back to you later. And next we're going to introduce. Our next speaker is Matt Pollack, who is the co-founder for KaBiomet. It's a Polish implant manufacturer and design company, is a polish implant manufacturer and design company, and we actually had a conversation quite a few years ago in a podcast interview fashion, and but I am pretty sure a lot has changed since. So, matt, why don't you start sharing your screen?

Speaker 3: 48:16

yes, can you see it, because I have started sharing.

Speaker 1: 48:20

No, because let's see, oh okay, let me just stop Bill's screen. Okay, there you go, there you go. I see it now.

Speaker 3: 48:30

Yeah, so, yes, initially, we had the opportunity to discuss a couple of years ago and a lot has changed. The size of the company has changed. As the first factor. I'm pretty honored and very honored to be the speaker at this event, especially that Bill Oxley is the speaker as well. So we are a kind of competitor, but not really. He's the leader and the top of the top in our world. So I'm just trying to follow with some successes.

Speaker 3: 49:04

But being a competitor, we, as a cambiometer, focus a bit on different things in these, in these days. So what has changed? I'm a medical engineer human medical engineer as a background. I'm not a veterinary surgeon, I'm not a veterinarian. So in our approach, we are trying more to utilize medical engineering approach and the medical engineering standards to the product, mainly focusing on implants, not the surgical guides. But since 2020, when the first implant and the guides for veterinary market were designed, we already collected more than 800 cases, so not 3,000, but we are directing to 3,000, I hope, in coming years. So pre-surgical models, training bonds, surgical guides, custom implants, but also some off-shelf products, milestones and clients. Actually, we ship all over the world our products, from Mexico through Europe up to Singapore. So first custom implant in poland was five years ago. Now we are providing our products worldwide, so a couple of clients also in uk, but the uk market is very difficult because of vet 3d, but still a couple of clients there, especially Polish surgeons working in UK communicating with Polish company just as a kind of um supporting a national company this way.

Speaker 3: 50:57

But um, one of our aspects which has changed during the years since our last conversation is manufacturing of workshop models. At Kabiomeda we manufacture models for the orthopedic training and since last three years we have changed our quantities from around 100 models per year in 2022 up to 1000 models monthly. When it comes to manufacturing, we provide models for orthopaedic training, manufacturing our own materials for 3D printing. So our models are behaving as a natural bone. They are not melting during drilling, they are not brittle. They are used worldwide, from mexico through greece to singapore, japan, tokyo, etc. So in this year we have achieved a capacity of manufacturing 1000 bonds per month when it comes to orthopedic models only. But building the brand credibility, since a couple of years we are constantly publishing at orthopedic congresses, so scientific posters, but also publications in veterinary surgery journals or biomedical engineering journals, and so last year we had the posters at three main congresses, not only in Europe but across the world, and at least a couple of publications to build this credibility behind the products and behind the company.

Speaker 3: 52:37

But what do we do exactly? I would say the same as Bill Oxley, but not exactly the same. There are a couple of companies like us, like Vet3D, like Cabiomeda, across Europe. So the market is pretty big and there is space for at least a couple of companies. So surgical guides work smarter, not harder. A kind of IKEA for veterinarians. Here you have that set of toys, here you have the manual do the job. But we are approaching this subject as engineers, so we are not proposing ready-to-use solutions. It's rather a kind of cooperation between engineer and the surgeon. As an engineer, we proposed two or three solutions, how the surgeon can approach the, the problem. But the surgeon is the, the person responsible for the uh for the patient. So it's more like cooperation than providing the, the solutions.

Speaker 3: 53:38

So anti-brachial deformities, a lot of deformities. But also training models for a very, very vast amount of orthopaedic trainings, from long bones up to school surgeries, dentistry, surgeries. As for now, we have more than 400 models for the training in our database and growing. So if some company would like to manage the training of antebrachium deformity in Dachshund, we can provide 20 of them in a quality providing the same feeling as drilling and cutting in the bone. So tons of the bones and the facility focusing mainly on bones, manufacturing like the wolf dentistry, as it was one of the models manufactured for the exotic hospital, as it was one of the models manufactured for the exotic hospital, focusing on the dentistry of the wolves. So material of the, the school, transparent teeth as natural tissue, but implants, mainly we focus on implants. I would say 60 of our custom-made products, or even 80 of our custom-made products are implants manufactured according to human medicine standards. So spine surgeries, ortho disease, quite similar cases to those presented by by building before, similar cases to those presented by Bill before, with a bit different approach as besides 3D printing we have also full possibility of CNC post-processing, polishing, cnc post-processing, cnc machining. The 3D printing is just the step in the whole machining process.

Speaker 3: 55:45

My favorite part of the business are partial joint prostheses manufactured according to human medicine standards and finished according to standards of knee implants in human medicine. But the size of patient is a bit different from 1.5 mini Yorkshire Terrier up to 60 kilo Cane Corso or 80 kilo Giant Breed dogs. So the smallest implant is around a chicken size implant I don't know if you can see in the camera. That's one of my smallest patients, whereas bigger ones are a bit bigger Still the size is a bit different than in human medicine, but here you can probably see yourself as it's a deep mirror finished surface. So a broad range of implants.

Speaker 3: 56:54

But there is a problem in veterinary market. Despite the products are perfect, the, despite the products are perfect, the software is perfect, materialized, which I'm also using, but not exactly mimics. There is a big problem, same as human medicine implant. Then there's a bit of problem because in human medicine you have to follow all of the standards ISO certification, fda certification. In US MDR, tons of paperwork, tons of standards, tons of paperwork, tons of standards, which is not present in veterinary medicine. In veterinary medicine, in most of the law systems, implants are not considered as medical products Because in the European Union the same in the United States, from what I remember medical product is intended to be used in human being.

Speaker 3: 58:05

Veterinary is not a medical science, it's agriculture in most of the countries. So if it comes to the standards, if it comes to the surface, finish, etc. It's like Wild West. Like wild west there are a lot of companies who are not following any standard, just manufacturing the implant and telling that it's a perfect implant for the animal, just use it. Responsibility of the company is like nothing, because if we don't have to follow the standard, no one can do us anything.

Speaker 3: 58:43

So the Caviomeda approach is a bit different, as we are following the standards and focusing mainly on the human medicine standards. So in human medicine you have to follow material biocompatibility testing, phatic testing, precision manufacturing all of the standards which provide you safety product, safe product with proper safety cleanliness that you can rely on. In veterinary medicine it's a matter of trust between the surgeon and the company. But if the company is a serious player and has a lot of money to invest in the process, it's okay. But if it's a completely new company from nowhere, telling that okay, our products are perfect, just use them, it's a bit risky to rely only on the kind of trust as there are no standards. So theoretically, implants don't have to pass biomechanical testing. They can be done out of anything because there is no specific standard for the material quality. Traceability, which is like basics in human medicine, doesn't exist. So if we have a batch of products in human medicine and one screw is improper by means of standards, manufacturer knows everything about the batch and can do the market callback etc.

Speaker 3: 1:00:28

In veterinary it's complicated Poor material choice, corrosion and rejection. Lack of precision, implant misfit, biomechanical failure, no standardized testing, breakage. And who is responsible for implant failure? The surgeon who doesn't know how to make the surgery? The manufacturer, the provider of material? The matter is very, very complicated so it has strict impact on the veterinarians and pet owners. If something will fail, who is responsible? If implant fail, it's always the responsibility of the surgeon because he is the user. But how he or she is checking if the implant, if the product is reliable, checking if the implant, if the product is reliable, it's completely different situation than in human medicine. So at least in our approach, we follow the quality standards of human medicine products. As from our responsibility, if something will be wrong, the company is responsible for it. The dimensions from ct. So if the software is validated, we can provide the precision certified medical grade materials in controlled medical processes, even if we don't have to follow it. We use it just because of this responsibility and credibility.

Speaker 3: 1:02:21

Biomechanical strength, testing, traceability. Every product has its number has full storage traceability in the system. So, for example, pgrs, custom made patelary groove prostheses from raw material through mechanical polishing, through electrochemical polishing, through final product form. It's a very complex process which at the end allows us to have the quality exceeding human medicine standard by means of surface quality. We are exceeding human medicine standards three times. We are exceeding human medicine standards three times. So how market will respond to the problem of growing and growing number of companies which are offering the medical veterinary products but they don't have to follow any standard because it's for animal? The thing is changing and from what we know from orthopedics associations, surgeons are trying to approach this problem and trying to incorporate some standards. Probably the long journey is in front of us. Standards. Probably the long journey is in front of us, but it's not so easy as just to take the software, do the guide and do the product how it looks in human medicine.

Speaker 3: 1:03:54

Is it just the surgeon is buying the software and doing the guides? Most of the time they are using medical engineers in hospitals. They have departments of medical engineering in the hospital, people who are responsible for the process. Who knows those technical parts? And if we would like to use the approach that veterinary surgeon now will become the engineer responsible for the product. It's, at least in our opinion, not not so good solution. Engineer is responsible for engineering, surgeon is responsible for the surgery. They should cooperate, not like. Engineer is not going to do the surgeries because he will learn the surgery within one month after buying the software. The same for the surgeon. Is it good to buy the software and do the job after two weeks? Not so easy and not so good. How long did it take to be precise and confident in designing the guides For Bill? After two weeks, two years, 2,000 cases in veterinary market. Every single patient is different. It's not like we have patients from 40 up to 80 kilos and everyone is the same. Every single product is a kind of prototyping and a kind of doing something for the first time.

Speaker 3: 1:05:32

Amount of deformation, amount of problems in animals is 10,000 times more complicated than in human medicine, is 10,000 times more complicated than in human medicine, especially when it comes to the deformity correction of a femur of the dog which is the size of a chicken. We are speaking about surgeries on newborn babies. Most of our patients are 4 kilos, 3 kilos, 4 kilos, so it's the size of a newborn baby. And then the level of complexity here is very, very, very high. One of my most complicated cases was the deformity correction with parallel prosthesis of this size of patient. Prosthesis of this size of patient, so it's 70 millimeters femoral bone with a deformity correction and with replacement of part of the joint. The cut school is this size if you need to put the plate on it and to have a full mirror finish of the plate for reconstruction of the skull. It's a completely different level of complexity than compared to human medicine.

Speaker 3: 1:06:53

Of course it's a bit different level of responsibility in human beings or in cats. But if we treat it just as a living organism and living being, the cat will have the same infection as human. If it will be not sterile, they will have the same irritation. If it will be not manufactured from proper material, the corrosion will be the same or even worse in animal organism because of the metabolism etc. So the biggest problem in a veterinary market, not only by means of 3D printing but overall, is the standards. Human medicine standards should be incorporated in veterinary market. And then we have human medicine standards for 3D printing, metallic 3D printing, polymeric 3D printing. So they should be used also in veterinary market. So what makes us different?

Speaker 3: 1:08:02

Cambiomenda and big companies or maybe not big because Cambiomenda is still quite small. We have like 12 people now with five engineers and almost 400 square meters of manufacturing floor floor but still that what makes serious company different is following the standards and really focusing on this engineering and medical engineering part, not just. I have bought the printer and I'm now doing the implants In human medicine. It will not work at all. You just can't buy the printer and print implants or print the surgical guides for orthopedic surgeon doing the elbow reconstruction in human medicine. It's if it's not working in human medicine, it should not work also in veterinary market. And I hope it will be a full standardization and full quality standards um demand and requirement in this in this market, as it's very, very, very complicated and complex part of the of the market medical market overall. Of the market medical market overall. Yeah, so with this positive outcome, that's all that I have for today.

Speaker 1: 1:09:33

Thank you, matt. Thank you so much for that presentation and good discussion about bringing veterinary medicine implant production quality to human grade. I absolutely 100% agree. And I do agree that self-regulation, as opposed to creating additional bureaucracy to regulate a space, is probably the best initiative right now, because I think it's always a balance between additional regulation in a space with bureaucracies versus. You know, we are going to self-motivate and do a good job. We have a question in the audience but we're running out of time, so we're going to move on to the next speaker to so that we can get to our panel discussion. But, matt, you can take a look at that question from Sebastian in the question Q&A box. But, matt, you can take a look at that question from Sebastian in the question Q&A box. Our next speaker I'm going to invite Dr Sinan from Vimex and also he's a co-founder. He's an orthopedic surgeon first of all and two. He co-founded several different companies focusing on veterinarian implants. He's located in Turkey, so thank you very much.

Speaker 5: 1:10:51

Dr Sinan, thank you, jenny, and thank you for all speakers. There is a lot of good cases. Thank you, bill, also for these good surgeries. It's really very fantastic to watch them. Thank you for all and it's really exciting for me to collaborate with you here in the presentation. Thank you for all and it's really exciting for me to collaborate with you here in the presentation. Sorry, I will just check.

Speaker 5: 1:11:07

Yes, I'm an orthopedic surgeon too and I was just teaching in the university. First of all, 10 years ago I found the TraumaVet company, which is just serving for veterinary orthopedic places and secretives, and I was just producing in subtractive manufacturing. And now we just built, two years ago, the V-Mix company which is doing the additive manufacturing. I will also talk more about this. But what we do? We have a lot of cases, just you showed, and I'm really very happy. But we have some problems. But we have some problems Sometimes. We all have some problems, some complications. I don't care if the surgeon's mistake or if it is an implant failure, but we all have problems and sometimes we cannot do anything without imaging a new system or a new solution. Look, there is a really big bone loss. It's a necrotic tissue just in the middle of the femur. One third of the femur is missing and this poor guy had a lot of surgeries and in the end he had a big loss of bone. And what to do? What's next? And then implant failure and then what to do? We just didn't have so much opportunities before. Additive manufacturing just touched our lives and touched our quality of surgeries and the also. The owner is also problem because she is also in pain. The dog is also in pain. We have a lot of texts, a lot of callings, but we have. We need some time and during the last five years we have now good imaging systems and imaging centers. The CT is much more available right now in our countries and doing the CT I'm just going quite fast for the surgeries because we really had a lot of fantastic surgeries. We have watched them and I'm just showing. There's also another imaging system center here in Istanbul. This is our company. Also. We have an imaging center because we need good images to make good implants for the manufacturing.

Speaker 5: 1:13:12

We are quite a big company serving veterinary doctors in a lot of fields and parts, a lot of fields and parts and you all know the softwares and see the bone and to deal as all other doctors and engineers has done before. We also do the same, quite similar prosthetic and cajun place together and also integration bone in growth. This is I'm really very excited about this because it's very fantastic. You you cannot even especially cases like with bone loss if you just put a cage, then I don't trust, only the secretes. Bone-osteo integration is the key and this is very fantastic, that our engineers have a lot of effort on this. They spent a lot of time and they just do a lot of improvements in those surfaces.

Speaker 5: 1:14:05

I will just talk in the next slide. And designing is really very exciting with engineers because doctors, especially orthopedic doctors with the engineers, are really great teams and I'm really happy to work with very talented engineers from BITEC company I will just talk about. We are just coming from Humansight and BITEC company and Kuntay is one of my friends and the head engineer in those companies has a huge experience in metal additive manufacturing and additive manufacturing and I'm very lucky to work with them. So we design, we decide and then in a few hours or in a few days we just have the implant. This is very exciting as an orthopedic doctor.

Speaker 5: 1:14:52

And then the case when you get in the surgery. It's super easy, it's super fun to just put and it's really very fast and you enjoy the surgery because before the surgery you just see the trajectory of the secretion and how you will send it, how you will read it and the drill guys is really making surgery very fast and very easy. This is what we really happy with. Additive manufacturing and in veterinary medicine is growing so fast. The acceleration rate is much more bigger than human medicine and I really love these surgeries. Look, uh, the owner was texting me in pain but in after a few months she's just texting me with really good videos. That makes me very happy. I know you feel the same. And uh, the orthopedic doctors in the last maybe five years they have problem with toyberries. We have a lot of toyberries in also our country and we have a lot of problem with these radial fractures. Even we do the place and sickles or external fixation that this little poor guy had a lot of surgeries and the last section was done with external skeletal fixation.

Speaker 5: 1:16:03

And if the standard implants are no more helpful, so what's next? What can we do? We were only talking about amputation just a few years ago, but now we have some solutions because we have now good teammates. We have friends, engineer friends, and we are just working together. These are very talented engineers from b-tech company, trap tech company and in vmix. We are just working together to treat our patients and for this little guy also. We have a lot of examples before, so I'm just going quite fast to catch the time. We just see the bone and just check the healthy bone and then make the guides to cut the necrotic bone and after perfect cutting the surfaces we just put a cage with a plate with osteointegration where we want and screeds also and to see the stress level.

Speaker 5: 1:16:58

Before the surgeries, to test, as Mateusz has talked about to test. They are really very fantastic. And also, neurosurgery is one of the greatest parts of additive manufacturing and 3D printing, because 3D printed guys are crazy good and doing surgeries, especially if you're using the pedicle secretives, the polyaxial secretives. Sending the secretives is quite hard and before the surgery we just print it, see the trajectories and try our guides and then get in the surgery and do our surgeries. This is a case from Julian. He is also a close friend of mine and we are just collaborating so much. Also, 3d printing helps us so much in trainings. Really, if you just are in training, even if you give the lecture, the attenders when they touch the bone or see the bone or before the surgery. Learning before the surgery. If you want to plan the surgery, it helps you so much in pre-planning.

Speaker 5: 1:17:59

Another thing is okay in vet also, we are just doing just straight plates and scripts. This is good. We can just contour the place. There are some rules for application of plates and scripts. But anatomic plates are getting more popular. So how to produce them, to produce an anatomic plate, is quite challenging when you just use the CNC machine. It's quite challenging when you just use the CNC machine. But if you're just printing them, then it has much more advantage. And another case from our studies is when you just bend the regular plates it loses a lot of strength. But if you're just manufacturing, additive manufacturing, and when you take the additive manufacturing part to CNC machining for a perfect locking scripts, then it makes really good difference. This is what we do. We also combine the technologies of additive manufacturing and CNC machines together, subtractive manufacturing together, and this makes very good implants and very, very good surgeries.

Speaker 5: 1:18:58

This is also another example from pedicle scripts. This is also another example from pedicle scliffs. And just see that there is a really tiny room to send the scliffs. So perfect, implantation of the pedicle scliffs needs really guys and we are very happy to make those guys. This is another case from Istanbul. My friend Efe he's just a dentist from Istanbul and we just made a prosthesis mandibular prosthesis for this huge tumor. This is another tumor from the same clinic. Let me just show you how to plan it. We just make the perfect cuts and then replace the implant.

Speaker 5: 1:20:16

This is how we plan and test it and then produce it and then to the surgery. We really had a lot of great surgery, so I'm going fast. This is another rostral mandibular tumor case with the implant and this is another case for reconstructive surgery. And additive manufacturing just lets me to use a lot of materials, not only stainless steel or titanium. I can just use peak and other polymers. We also develop some resins, bioresins, and then we use them, check them. This is also super flexible for a surgeon.

Speaker 5: 1:21:12

This is another case with second lumbar section tumor. We just plan and make a corpectomy and then design the implants, send the guides for the surgeon for a perfect and easy surgery. This is also the implant. This is another female case, a cage with a plate, because if we don't have them, then we have really big problem. Amputation is not a solution for us. And we just do the vertebral spacers for Wobbler syndromes. We do a lot of spacers. We just do the ITAP prosthesis, which I will show a small video of a dog.

Speaker 5: 1:22:00

Really, guys, and this is the first case I think, of the world this is from the BBC and NBC news. It was a sea turtle was injured from maxilla and mandibula and B-Tech company has made the first implant titanium 3D printed implant for it and after just five years we just built a new company which is called VMIX, and our partners are Hossvet, btech, traumavet and Traptech. These are mother companies and this is just a sister company for Traumavet. We are just doing the CNC machining and additive manufacturing together. But what we do is not only having the software and just a printer and then the print. We have a really big experience because our team has 35 engineers working inside the company and they have a huge experience from Huma's side, and it's not only a software and a production.

Speaker 5: 1:22:54

We are deep in developing new technologies, new processes and new values and new applications for veterinary use, new processes and new alloys and new applications for veterinary use, especially testing and developing new alloys which we can easily clean, which we can easily print and cost-effective. We also do optimizing about these new alloys, because innovative alloys in veterinary applications will change quite a bit. Again. We are testing strategy new alloys for veterinary application using additive manufacturing. Unlike the medical sector, the veterinary market offers faster opportunities, allowing innovative materials to be adapted more quickly, as Matos has told. But I'm just talking about the first period because we are just conducting extensive research on materials of medical applications. However, strict regulations mean that even a proven material can take years to reach to the market. But, in contrast, the veterinary sector presents a more flexible landscape, creating a significant opportunity for additive manufacturing and innovation and also integration which I really love it and optimizing the bone engraft.

Speaker 5: 1:24:08

We just check the density, the porosity and the microstructures for the perfect osteointegration for the implants. This is how our engineers spend their time. We also check all the powders. Our engineers spent their time. We also check all the powders the titanium powders we use under electron microscopy to have the better medical products. We test all the materials and we just use the same regulation as human medicine uses and we just use a lot of effort and money to produce the best implants and we just have some certifications from non-stotoxicity and others. This is what we just created new powders, as I told you before. We have a lot of designs and cases. We have some experience in veterinary field, but we are always open to collaborate with other companies. We are so open to collaborate and just develop new technologies together.

Speaker 5: 1:25:08

This is pedicle surgery guides, as I told you before, and another part is to guide assistance of the surgery, because we just send the document to the surgeon, which makes the understanding of the surgeon the implant is in a better way. This is a photo from an ITAP case from a cat. This is a small movie in Turkish but there are subtitles. I just want to show it to you because this little poor guy is living on the streets. He's a stray dog and had a terrible accident. He had a lumbar fracture, he had a surgery with pedicle secretes and in the left side he had an arthrodesis and in the right side he had an amputation. But we just made the ITAP prosthesis. This is a case which we really spent a lot of time. Let me show you this is what we really love and why we do it.

Speaker 5: 1:26:52

And, as a doctor, what do I love about 3D printing? The osteointegration makes it easier. Really, I love it. And dreaming and creating something is super, extremely good for me, because I also know some surgeons. They love to design, they love to use the mimics and other applications and they do their own segmentation. This is what is fun for them. And to plan a surgery is also very fantastic. And with 3D printing you are quite limitless. You can imagine other solutions and you can use a lot of materials. There is a lot of variations of materials and preoperative planning is very easy with 3D printing.

Speaker 5: 1:27:37

Perfect secretive implantation is very important in neurosurgery and what I love about 3D printing as a producer is much more time effective for prototyping. Just on my desk I'm just trying to make a new implant and I have 3d printed bones and 3d printed designs and I just always try. I always work with them, so it's quite good for me time effective prototyping because when you dream and just throw the plate, then setting the cnc machine and producing it and testing it, it takes quite much more time and creating a new implant with additive manufacturing is super easy and you just don't have a lot of loss of raw materials Shapes doesn't matter anymore More than atomic solutions for veterinary orthopedists and you just don't spend a lot of money for stocks and combining technology and materials like locking screws. We just do the locking screws in our traditional CNC machines. We just take it from the additive manufacturing to CNC machines. They make it a perfect implant and sometimes we do the place and screws and cages together, especially in TTA surgery.

Speaker 5: 1:28:56

We have the CNC machine, tta and 3D printed CTA and osteointegration is super crazy. In 3D printed TTA. You can just combine them, we just put them in ourselves and there is no more stock cost. This is what I love in 3D printing as a producer. This is what I love in 3D printing as a producer, and I think that in the next feature we will have biomedical and medical engineers in the hospitals and some 3D printers and we will just assist them. The feature will change. We will just carry our factories into the hospitals. Thank you very much.

Speaker 1: 1:29:37

This is what I will just talk about 3D printing in veterinary medicine. Fantastic presentation and love how you work with Kunte, who I will consider a friend of mine as well. It really demonstrates the value of collaboration. We're running out of time so we have to leave all the questions at the end, which should be soon. So if you have any questions, please put them in the Q&A box so Dr Sunen can address later. We're going to move on to our next speaker, luca Manassaro, also Dr Manassaro, from Italy. He is also doing his PhD right now, focusing on the 3D technologies in veterinary medicine. So, luca, I'll let you take over, but please keep in mind that we do want to leave 15 minutes at least for a panel discussion at the end.

Speaker 4: 1:30:23

So, yes, I will be really quick with my presentation. That's also a little bit different compared to the one already performed. Just a sec, okay, I hope you can see the presentation. Yes, perfect. We don't always have the last machinery compared to human medicine, and so following some tips could be very helpful, especially considering that we are not always performing the CT ourselves. A lot of people are just sharing the cases with us, and so maybe giving some guidelines could be helpful. So I work in radiology at the veterinary hospital in the University of Turin in Italy and of course, I'm a big fan of 3D printing. I think that the first anatomic models for students and also to visualize to help to visualize surgeons some complex cases were done close to 10 years ago, years ago, and from a couple of years we are also performing some guide system for the correction of limb deformities.

Speaker 4: 1:32:26

Doing the imaging for 3D printing. We can use a variety of methods. We can use a variety of methods. Of course, the most popular one and we will see why is computed tomography, but we have also to consider other imaging modalities like COM-beam computed tomography, also MRI, ultrasound and some optical scanning method MRI, ultrasound and some optical scanning method. The right imaging modality depends on the anatomic area and also the clinical needs. So why CT is the preferred CT, the preferred modality for 3D printing? Because CT is very superior with resolution compared to all the other methodologies and is also very fast to acquire the images and also, I can add, everybody can do the job. Compared to CombinCT, combinct has a very good resolution on bones and also a big advantage that it's not involving too much veterinary medicine. That is low dose radiation compared to computed tomography. But for example, even human medicine are using also this modality. Ultrasound generally lacks of volumetric data, so that's why we prefer CT and optical scanning for sure can only scan external surfaces and cannot scan organs or bones. So the big advantages of CT for 3D printing are the high spatial resolution. That generally is that generally is below one millimeters. It's very fast and versatile compared to the other modalities. But we will see also that MRI can play a big advantages in evaluating soft tissues et cetera, but is less automatic than CT, is less automatic than CT Comprehensive bone tissue. So the CT can scan in a very good quality both bone and soft tissue. And also we have to consider that CT is widely available in veterinary clinics, especially nowadays In the last few years. A lot of clinics have their own CT, so this is for sure a big advantage.

Speaker 4: 1:35:25

There are some key considerations for CT scanning in veterinary medicine. The first one is the need for anesthesia or sedation, because animals cannot remain still like human patients, and also the need of anesthesia is helpful to reduce motion artifacts. We have also to consider the positioning, so using special support, etc. And we have to consider some acquisition parameters because, yes, as previously mentioned, in veterinary we don't have the last machinery compared to human medicine. So taking into consideration some parameters can help a lot in having a good image to post-process than for 3D printing.

Speaker 4: 1:36:25

These are some parameters that we have to at least know to get the best signal to noise ratio. We have an example on the right there is a dorsal view of a city and we have a lot of, let's say, mistake in this acquisition. So so on the top you can see some lines that are actually some breathing artifacts and are not so welcome in a segmentation process. And also on the bottom we have a lot of noise. This noise is given by radiation that is not going through all the structures, so there is a lot of noise, and here we can for sure get a better image. So getting a better image, we have to consider milliampere seconds, so the quantity of the X-ray, the more. The more we have milliampere second, the higher signal to ratio we get. Also, the kilovolt play a significant role in it.

Speaker 4: 1:37:43

But we have also to consider that the more we increase these parameters, the more our CT is hitting, and so it's not possible to acquire a total body scan with very high milliampere seconds and very high kilovolt. For example, slight thickness play also a role in reducing the signal to a noise ratio. So the thicker the slice reduce the spatial resolution, the patient size, the the image of this on the right is pretty big patient and so the bigger the patient is, the harder to the x-rays is to get all the structure et cetera. Another one is the pitch. The pitch is the rotation of the tube along, the movement of the bed in the CT and the rotation time of the tube. So there are some parameters that we can optimize. I think that there is not the best recipe for anything, but this could be taken into consideration and maybe given as guidelines for who's taking the imaging of our region of interest.

Speaker 4: 1:39:20

So nowadays not a problem to maintain one millimeter for the total body scan because most of the scanner are multi-detector ones and we don't have so many problems. But of course with some scanners we can get some heating problems in having the whole body scan in just one acquire. We have also to consider the fove. A lot of time I receive images that are done for the whole body and maybe just a bone of the, I don't know, the forelimb is the region of interest, maybe the carpus, and we get some pretty annoying artifact, let's say, because on the left you can see the previsuous image, just zoom in and we have a lot of just steps around the cortex of the bones and these are not helpful for the segmentations, while on the right side we have a reconstructed image of the same scan, just with the proper reconstruction FOV, and this is crucial to have a very good image to post-process, taking into consideration the positioning.

Speaker 4: 1:41:10

For example, in here we are seeing a scan for limbs and over a pretty small patient and in here we use normally for limbs dorsal recumbency, the use of cautions to support and align the anatomy and also the limbs have to be moderately extended to the gantry and also to be a little bit distanced between the two and directly the bone of interest should be placed at 90 degree angle compared to the CT gantry. Okay, this is a funny image. So we are vets and we scan a lot of different animals and we have to consider that we can run into some funny situation. So normally we work only with dog and cats. But some patient, like for example the duck, don't need any anesthesia, it's just best to lay down with some towel around her and no problem with the CT scan. Also we have some very small patients and this is pretty challenging to get a proper resolution resolution and also some long, very long patient like the white snake on the center and yeah, with just one scan is not possible to take all these animals in one scan.

Speaker 4: 1:43:07

And then also, for example, on the top left the eagle is with some very peculiar anatomy. So the bones, for example, are full of air. So in the slicing the segmentation is not so easy at all. Here we have a common mistake for a motion artifact on the radius. So you see the radius as a small step and this is just a breathing artifact. A CT like that to reconstruct and maybe do a limb, angular limb correction would be not so ideal to make guides system on these artifacts. So the proper scan is on the right and this is without the motion artifact. This looks like just a fracture.

Speaker 4: 1:44:23

We have also metal artifacts and they are very hard to deal with and we have some algorithms and they depends on the CT scanner mainly, and also other artifacts.

Speaker 4: 1:44:41

There are a lot of artifacts to deal with, like the beam hardening artifacts or the volume averaging where can go with a very poor quality anatomy reconstructed.

Speaker 4: 1:44:58

So in general, I think that the better the acquisition, the fastest the segmentation and the better the 3D model will be. So we have to keep in mind what we have said, because there is no just do the model, and here's the CT. We have to think about a little bit, just a little bit to the CT, because the CT nowadays is very simple acquisition compared to some years ago, especially in veterinary. Nowadays we have good scanner too and so with just a few little points we can get a good model for our engineers and of course also for radiologists, because I'm a radiologist and I think that I can be put in the middle between the surgeon and the engineer to try to make the collaboration better. So I think that the segmentation of the anatomical structures is our job, and so we should interface more between the engineer and the surgeon, trying to speak the same language, or both, I think. And with that I'm done, thanks.

Speaker 1: 1:46:19

Perfect timing, Luca. I was just going to tell you. Our time is up. Thank you so much for this presentation. I'm also a radiologist, so this is very interesting to me In the back of my head. Actually, in our private conversations I'm talking to matt about taking a look at a dolphin ct, if he can allow me. So I think now is a good time for panel discussions. So if our panelists are still online, uh, please join us. I'm going to stop sharing in the screen of luca here. Luca, you can share your email in the chat box. Um, so if you want people to get in touch with you in the chat box, so if you want people to get in touch with you, that will be great. So we have a couple of minutes.

Speaker 1: 1:46:58

Actually, I think this panel discussion is quite important because I think right now for 3D printing industry as a whole, I think the industry is experiencing a bit of a downturn lots of pessimism, companies being acquired or merged. It's a bit of a nadir of the industry. So, and another interesting conversation I had recently was with a orthopedic 3D printing implant veteran, and so my question is what do you think the longevity of this technology is in this industry? I mean. Could it be that one day surgical guides, for example, will not be necessary and instead we're just going to use robotics and software to guide surgery? That's one, and number two is do you think 3D printing will be definitely a growing sector in manufacturing implants? And this question is definitely more relevant to people the speakers who focus on implants. So I should just have a sense of where the future lies for the industry. I will open up to our first speaker, Brad first, and then Bill, Dr Sennan and then Matt and Luca.

Speaker 2: 1:48:21

Yeah, and this is something that Materialize has considered as 3D printing viable for the long-term future. That's why we've looked into and we started working and developing in the augmented reality and virtual reality space working and developing in the augmented reality and virtual reality space. We do have one veterinary surgeon that's used augmented reality within the clinical setting, just as Bill showed, and it's a viable way forward if 3D printing is on the way out at some point in the future. But I mean in terms of that, versus traditional manufacturing, 3D printing is much more accessible and can fit into a much smaller space. So I think there definitely will be a use case moving forward. It's just how large or how much it grows from there I really don't know, but good question.

Speaker 1: 1:49:17

Yeah, Bill. Do you have any thought about the future?

Speaker 6: 1:49:20

um, I I think, um in terms of guides, I mean, I I've no doubt one day, you know, robotics will or other forms of navigation will supersede guides, but I don't think that will be for quite a long time, especially in veterinary. I think the the degree of accuracy that you you need um will, I'm sure one day be achievable, but I don't think that's going to be for quite quite a while. Um, and I think the the cost of guides, even even if you're doing one every week, I think for a long time that will be sort of more cost effective than a high-level piece of guiding equipment.

Speaker 6: 1:50:07

So I think guides will be around for a while, quite a long time actually, but yeah, sure it'll come. I mean it's going to be. I mean, goodness knows where we'll be one day. Yeah, it'll be incredible, um, incredibly different thank you um dr sunan.

Speaker 1: 1:50:26

What do you think?

Speaker 5: 1:50:27

yeah, for me I think with machine learning, uh, just creating guides would be easier and everyone will be doing it. I think that most of the surgeons, especially veterinary surgeons, will have some 3D printers in their clinics the surgeons, they will love guides. But in the next feature and it's very close, I am agree with Bill the navigation systems and AR VR technologies will take the advantage and in the next feature the guys will not be so much popular and for manufacturing of orthopedic implants is challenging. But I think that we will not have only one factory which is full of CNC machines and there will be CNC machines and additive manufacturing together for a while, but then in the next feature, I think there will be additive manufacturing only for producing of orthopedic implants.

Speaker 1: 1:51:26

Wow, that's a pretty bold statement, but I think a lot of people on this webinar would like to hear it, matt. What do you think? The future?

Speaker 3: 1:51:38

It's complicated by means of just replacing the guides with robotic arm or just specific robotic solution to provide more and more accuracy.

Speaker 3: 1:51:51

Probably then it will be the situation that every single clinic needs an engineer to set up the robot. It's not the situation that the robotic arm will just know what to do with AI driven something, etc. So from my point of view it's not a big change if it will be going from designing the guide up to programming the CNC robot or the robotic arm which will do the surgery in the surgical room. But the costs the basic robotic arm with six degrees of freedom is like 100 000 or something like this. So for medical purpose it will be one million. Because you need to have this zero at the end for certification and safety reasons and probably by means of costs and because of the costs it's not the closest future. The another risk regarding the guides is that all of those fancy small toy breeds with you know problems will be forbidden. Like the only breed available allowable on the on the market will be a completely healthy dog, then we will have a problem. I think that the problem of replacing guides with robots is not the closed future.

Speaker 1: 1:53:27

Yeah, probably not as much of a concern for the human market, luca, what do you think?

Speaker 4: 1:53:32

Yeah, I think that it's very fascinating that we can also think about virtual reality or augmented reality in the terms of a guide system. So get rid of guide and just use maybe some goggles for the surgeon that apply to the anatomy of the bone and making the cut. I think that the 3D printing Uh-oh sorry.

Speaker 4: 1:54:05

A lot of advantage compared to augmented reality and virtual reality. I mean, just a piece of the whole operation could be done maybe with virtual reality, but 3d printing would be for sure. Uh, very useful for the last step at least.

Speaker 1: 1:54:24

Yeah, for the implants, for the alignment of the anatomy, etc yeah, the reason I mentioned is because last week we just did a webinar focusing on human orthopedic implant devices and all the major public implant companies now have a combination of implants plus robot, so they actually generate a lot of revenue from selling these robots, and these robots specifically work for their 3D printed implants. These robots specifically work for their 3D printed implants. So it's a very interesting pathway that the major players in the human market is playing. But, like you guys just mentioned, the vet is very different. The patients are a lot harder to predict and customize for. So, luca, since you're still getting your PhD, I want to start the next question with you. Is the next generation education for you know? And if not, how are the next generation learning about this?

Speaker 4: 1:55:43

Yeah, I hope that 3D printers are more applied in the university, for example, and we are using it for some student, but still just in the maybe space special areas. I mean not for every student, because especially in italy we have a lot of students, so it's not thinkable of managing hundreds and hundreds of bones, at least maybe for the happiness of Mateus could be very happy to print a lot of bones, but in terms of economical reason it's not the best. But still, we are using it for showing the case and it's very helpful for the education and it's very helpful for the education, but at this point still a small batch of students may be really interested in the topic.

Speaker 4: 1:56:41

Not for every student.

Speaker 1: 1:56:44

So you have to really.

Speaker 3: 1:56:45

Okay, go ahead If I may. Tomorrow I have a lecture for University of Padova veterinary students regarding applications of 3D printing, so it's more and more present in the programs. It's not like they will have full 3D printing subject for the whole semester or something I see, but at least for the University of Padova. They asked me last week to provide the lecture for veterinary students. What is the current state of market by means of 3D printing and by means of 3D printed bones? Actually, we sent quite a lot of 3D printed bones to Italian universities, italian universities, so more and more students are aware of the technology and the better for us as a company providing such services.

Speaker 3: 1:57:43

But, as I'm trying to always put some focus on it, it's not the situation that if you ask a company like mine, or Bill or someone who is providing surgical guides, that with our product, the surgery will be easy. It's not working like this at all. Those products are for very, very difficult surgeries to be less difficult. So it's not for easy approach that I'm just after the studies. I have zero experience, but I will print everything and do the surgeries. It's for making extremely complex cases, just difficult cases, and it should be always uh, underlined that cases, and it should be always underlined that it's not to make life easy, it's to make life easier from very difficult to just difficult.

Speaker 1: 1:58:44

Dr Sunnen, do you have any thought on the education for the younger vets?

Speaker 5: 1:58:51

For younger vets. I think that the VR and AR systems will not be available for that much people, but I think 3D printed bone models and surgery trainings will be really very good because just basic principles of bone plating and sequels there was a question about dynamic compression holes or something To understanding those biomechanics and those forces, those torques, bone-like materials really work very good. And for orthopedic education, I think that 3D printing will be very useful for the students and education.

Speaker 1: 1:59:28

Good point, Bill. What do you think?

Speaker 6: 1:59:32

Yeah, I think everybody's covered it. I mean, I think at student level this will always just be something that people kind of need to know is available. I think, as matthias said, these are these are generally sort of more complex surgeries and it's kind of it's the kind of thing that you're going to learn in a residency and you know potentially sort of advanced general practitioner level. But the really difficult surgeries are really residency learnt and it's very much like a hip replacement or something you as a vet student you're going to know about hip replacements, but you you're not going to know details and I think probably at the certainly the more advanced levels, um, that's very much where I think this will be in terms of the surgeon's journey through the education process. I think it will be at that sort of resident type level, um, or at least a sort of advanced orthopedic course time.

Speaker 1: 2:00:28

Yeah, yeah, I mean, I was actually very impressed when you said that now your service really focused on the design process, which I think is the hardest part is being creative. The real cerebral part is not the mechanical part, it's the creative, innovative for every single case. How do you do a best job?

Speaker 6: 2:00:49

That is the hard part for anyone.

Speaker 6: 2:00:52

Absolutely, jenny, it's so true. And I think the things that we've discovered through this process, with the ability to analyze deformities in 3D it's a new field, I mean this just didn't exist. And the previous mechanisms by which we did this, which is still taught, you know, even to specialist surgeons they're not wrong, but they're not really as comprehensive as they need to be. And we have a huge problem in terms of educating specialists with these new techniques, because people just aren't taught them. So we're kind of teaching some of this stuff as we go along and innovating it at the same time.

Speaker 6: 2:01:34

And the yeah, I think it's important to understand that. You know, everybody said it it's not just making a guide. It's understanding the, the deformity that you're treating or the problem that you're treating, understanding how the, the surgery that you're planning will interact with the biology and the mechanics, and understanding how the guides and implants will interact with that to achieve the clinical results. And that's where I think just chucking a thousand cases into some deep learning and trying to get AI to produce a guide system, that's where the challenge is going to be, because it is so much more than just working out some angles and doing some algorithms. It's a lot more complex. But this is the challenge and it's exciting. But I think the challenge is underestimated sometimes.

Speaker 1: 2:02:24

Yeah, absolutely, brad. We're going to wrap up with you. What do you think? How is Materialise helping the schools and educators with bringing this technology into more common practice?

Speaker 2: 2:02:38

I would say yeah, so we have a Mimic student edition. It comes with a course book that's pre-prepared and comes with the student licenses that can be used by the teacher and the students to teach in a course, and all the grading can be done there in terms of and this is for VET.

Speaker 2: 2:02:59

This program is for VET. We're developing stuff for VET. Obviously, material I was initially developed for, you know, academia, university and human use case initially, so we're working to develop that as well. We do have a mixed user certificate program as well, where you can earn a certificate. It's done online and can be graded online and be done at your own pace as well.

Speaker 1: 2:03:23

Yeah, maybe you can consider collaborate with some of the speakers here, because they obviously have a lot of experience and they already taught me a lot, so they're great teachers, no doubt. Okay, everyone, thank you so much for sticking to the end. We are a very small but passionate group about 3D technology and veterinary medicine and appreciate your time. This recording will be online for a couple weeks for free and you can invite your colleague or students to watch, and we will also share interesting segments online as well. Thank you very much and I'll see you next time.

Speaker 2: 2:04:00

Thanks everyone.

Speaker 1: 2:04:01

Bye-bye. Have a good night and good day, bye-bye.