1. Z Corp. Medical Modeling Solutions Improving Patient Outcomes With 3D Precision

2. Agenda Leading Customers Applications and Case Examples
Emerging Applications
Additional Capabilities
Technical Requirements
The Z Corp. Advantage

3. 3D Medical Models
Z Corp.’s 3D Printers enable surgeons to rapidly produce inexpensive 3D models to obtain better case information to reduce operating time, enhance patient and physician communication and improve patient outcomes.
The speed of Z Corp. Printers enables 3D models to be used for trauma cases; a significant advancement for use in the medical field.
The use Z Corp models by physicians in a variety of specialties is becoming increasing more popular as a result of the recent launch of the company’s entry level, monochrome 3D Printer, the Z Printer Further contributing to Z Corp’s growth in this segment is the Z406 3D Printer, the only full color rapid prototyping machine in the world. The Z406 is also the worlds fastest RP machine.
There are many reasons physicians are using 3D models from Z Corp, but the primary reasons are that they obtain better case information, reduce operating time, enhance patient and physician communication and above all, improve patient outcomes.
One of the greatest benefits of our technology is that the shear speed of our Printers enables medical models to be used for trauma cases, an area where no other technology can compete.

4. Diverse Customer Base Service Bureaus Orthopaedics & Maxillo-Facial
Medical Modeling
Javelin 3D
Stereolithographers
Pediatrics
University of New Mexico
Orthopaedics & Maxillo-Facial
University of New Mexico Medical Center
Seoul National University
Plastic Surgery
Fukushima Medical University
Clinica Olinda
Faminsa
Implant Manufacturers
Synthes
EBI
Here’s a list of some of our current customers grouped by medical application. You can see that this list of customers is as diverse as it is global, with surgeons in the most common disciplines we already discussed, to several leading implant companies, to a few of the worlds leading medical rapid prototyping service bureaus. (read list)

5. Applications and Case Examples
Enables pre-operative analysis of complex total hip replacement
The next series of slides contains details about the many different applications and provides a few real life case examples of each.
Pre-operative sizing of uni-compartmental total knee replacement

6. Leading Applications Pre-surgical planning Implant pre-contouring
Screw trajectory
Screw selection/location
Instrument selection
Technique rehearsal
Custom implant manufacture
Physician to physician communication
Powerful patient presentation tool
Medical student/resident education
3D Surface Scanning/Custom Prosthesis Design
Here’s a look at the many different applications that Z Corp 3D models are now being used for. Perhaps the most popular use is that of pre-surgical planning. There are five specific areas within pre-surgical planning where the advantages of 3D models are very useful. These are Implant pre-contouring, screw trajectory, location and selection,, screw selection, instrument selection and technique rehearsal.
Custom implants is an area we are seeing quite a bit of interest in with leading suppliers fabricating custom implants directly against 3D models made from patient’s CT data. These manufacturers are able to make custom implants faster than ever before with greater precision.
Our models are also very useful as communication tools. Physicians often use them to communicate the intricacies of multi-disciplinary procedures as well as to communicate on the most basic level to patients. Physicians find that a higher level of patient confidence in the physician is established when the use of a medical model is present.
Another very useful application for the technology is for the training and communication of complex issues and procedures with both medical students and interns.
Finally, 3D scanning of surface information is an emerging field in the area of custom made prosthetics.
We have a few slides on each of these applications that will explain them all in greater detail.

7. Pre-Surgical Planning: Implant Pre-contouring
Z Corp. models enable implants to be pre-contoured prior to opening patients
Significantly reduces O.R. time
Lowers cost
Reduces O.R. team fatigue
Enhances patient outcomes
Reduces “re-do” procedures
Minimizes size of incisions
Speeds recovery time
Improves anatomical alignment
Bone “sucks in” to the plates
Enables multiple procedure rehearsals
Implant pre-contouring is a fascinating application as it enables physicians to literally fit implants to the patient model well in advance of the surgery, an approach that often saves hours of O.R. time and dramatically reduces the time in which patients need to recover. Less time in the OR means a significant reduction in cost. At an average of $2K per hour, OR time is a precious hospital commodity. Reducing it not only means a pure savings of dollars, but a significant reduction in fatigue experienced by the surgical team, let alone the reduction in in-hospital recovery time required by a patient. Another money saving benefit of the technology.
Because pre-contoured implants are more accurate and fit the first time, anatomical alignment is so good that the amount of “re-do” procedures is significantly reduced. Again, substantially saving money, time, aggravation and discomfort for all involved.

8. Case Example: Maxillo-facial Surgery
Z Corp. models used for facial trauma cases can be sawed apart and re-aligned for proper anatomical fit of pre-contoured plates
Bone virtually “sucks” up against the implant, insuring a perfect fit
This is an excellent example of a case in which implant pre-contouring is extremely valuable.
The situation at hand that spawned this case was severe facial trauma to the skull. Here the CT data is printed and the model evaluated. The maxillo-facial surgeon then cuts the affected areas apart from the model and reassembles them into their proper anatomical position using our cyanoacrylate adhesive or wax. Now with the bone structure properly aligned, the necessary implants are pre-contoured to the model, greatly improving the speed at which the surgery can be completed and the precision of the fit of the hardware.
Dr. John Wagner, a maxillo-facial surgeon practicing at the University of New Mexico’s Health Science Center states that “the pre-contoured hardware fits so precisely that the fractured bone being repaired virtually “sucks” up against the implant, improving the precision of the fit dramatically.

9. Case Example: Maxillo-Facial Surgery Mandible Reconstruction
Pre-contoured mandible plate reduced time in the O.R. by 45 minutes
Dr. Fernando Urrutia Plastic Surgeon (Mexico City, Mexico)
This maxillo-facial surgery case had a very noteworthy result. By pre-contouring the mandible plate shown in this photo, Dr. Fernando Urrutia of Clinica Olinda in Mexico City, Mexico reduced the amount of time spent in the O.R. by 45 minutes. Again, saving real dollars, minimizing surgical team fatigue and speeding the patient’s recovery time.

10. Case Example: Orthopaedic Surgery – Acetabula Reconstruction
Pre-contouring acetabula fixation plates can reduce O.R. time by as much as 2 hours
Incisions can be reduced from over 12” to as little as 4” in some cases
Dr. George Brown Chief, Division of Spine Surgery University of New Mexico Health Science Center Albuquerque, NM
Complex pelvic and acetabula fracture
This case presents one of the most useful applications in the field of orthopeadics. Acetabula reconstruction is one of the most challenging operations facing orthopeadic surgeons. By pre-contouring plates and determining such things as screw location and length, Dr. George Brown from the University of New Mexico’s Health Science Center, has reduced time in the O.R. by as much as 2 hours. Additionally, the size of the incision required to perform these operations can be reduced from over 12 inches to 4 inches in some cases, again, speeding recovery and saving money.
The photo here show a Z Corp model of a complex pelvic acetabula fracture.

11. Pre-Surgical Planning: Screw Trajectory
Z Corp. models are used to analyze fractures and determine the precise location and trajectory of alignment screws and fixation plates
Another great application for Z Corp models is that of using them to determine the best location and trajectory for alignment screws. The picture here shows a Z Corp model of a complex, bi-lateral, pelvic fracture.
Here a set of screws have been inserted in the model to enable it to be re-assembled prior to surgery.
Complex bi-lateral pelvic fracture

12. Pre-Surgical Planning: Screw Selection and Location
Z Corp. models permit detailed analysis of bone mass to enable screw length selection and location to occur pre-operatively
Reduces O.R. time
Improves fit of implant hardware
Screw selection and location is another great application for Z Corp models. The photo here has been marked by ink pen to show the exact position of where the screws should be located. Surgeons then find it useful to determine the length of the screws ahead of time and mark this information on the models as well. This eliminates the tedious, difficult task of taking measurements during surgery just to determine how long a screw must be.

13. Custom Implant Manufacture
Z Corp. models permit the world’s leading implant manufacturers to fabricate custom implants rapidly and cost effectively for the ultimate in performance
The manufacture of custom implants is another area where Z Corp models are being commonly used in the medical area. In fact two leading manufacturers, Synthes and EBI use Z Corp models for the design of custom implants.
A chin implant is shown attached to the Z Corp model in the upper photo and a cheek implant to the model in the lower photo.

14. Case Example: Custom Implant Manufacture
Silicone septum implant was constructed and fit to the Z Corp. model saving 1 hour of O.R. time
Dr. Fernando Urrutia
Plastic Surgeon
Clinica Olinda
Mexico City, Mexico
Here we see an interesting case where the silicone septum implant was designed and fit to the Z Corp model pre-operatively, shown above, prior to being inserted in the patient’s nose. Again, another excellent example of how OR time can be greatly reduced as this operation was completed one hour faster than expected using traditional techniques.

15. Enhance Physician to Physician Communication
Z Corp. models permit excellent communication between physicians and surgical teams; particularly useful in multi-disciplinary cases
Particularly useful in cases where surgeons from a variety of disciplines will converge on a single case, Z Corp models enable them to more clearly communicate the surgical paths they wish to undertake with colleagues. Again, another example of how improving communication with Z Corp models can result in better choices, proper planning, faster procedures and better patient outcomes.

16. Patient Communication Tool
Z Corp. models enhance the physician’s ability to communicate with patients; raising confidence in the surgeon and the likelihood of a successful outcome
Surgeons are also using Z Corp models simply because they permit very complex medical explanations to be more easily communicated to patients. These models personalize the diagnosis and improve the patient’s confidence in the physician’s approach to their specific case.
Silicone cheek implant

17. Medical Student/Resident Education
Z Corp. models prove very useful in communicating with students and residents
Complex 2D images can be converted into easy to understand 3D models that can be held and easily manipulated for a more complete understanding of the anatomy
Z Corp. models are also very useful in teaching medical students and residents techniques in reading 2D CT and MRI images, as well as how to perform a specific procedure. Additionally, full color 3D models permit other areas of the anatomy, to better understood from the data.

18. Emerging Applications
As you would expect, as Z Corp. technology grows in popularity, there are a few other very interesting applications that are starting to emerge within the medical field for our models.

19. Cardiology
Advancements in CT technology now permit 3D capture of soft tissue data
Physicians can better quantify size, shape and function of the heart.
Examining the whole, beating heart makes examinations and surgical procedures more precise and rapid.
Cardiology is a very interesting field where advancements in CT imaging technology how permit the 3D capture of soft tissue data on beating hearts. This will prove very useful in enabling cardiologist to better quantify size, shape and function of the heart.
Simply put, examining the whole, beating heart, makes examinations and surgical procedures more precise and rapid.

20. 3D Surface Scanning/ Custom Prosthesis Design
Utilizing 3D surface imaging technology; custom prosthesis can be fabricated from Z Corp. models used as patterns for the development of molds
Surface scanning is an area that is emerging as an interesting medical application. Here is how it works: patent data is captured using either a 3D camera, (Minolta) or a 3D scanner (InSpeck). (Z Corp. has very close relationships with each of these companies.) For example, in the example here we see an application where a prosthetic breast must be designed. To accomplish this, a 3D image of the patients healthy breast is captured using either the scanner or camera. It is then imported into our ZPrint software and printed. The 3D model breast is evaluated for form and fit prior to moving to the next phase. The negative of this model is then created in the data and used to design a mold into which the silicone implant material will be cast.
Both Minolta and InSpeck are working to constantly pioneer new applications like this in the medical field and Z Corp. is proactively working with each company.

21. FE Analysis
Full color Z Corp. medical models enable surgeons to better understand the affects of impact and compressive stress on bone to anticipate additional areas of concern
Another great application that Z Corp is aggressively investigating is the use of full color 3D models that have been analyzed using finite element analysis tools to measure the affects of impact and compressive stress on bone to anticipate additional areas of concern to better understand the injury. Z Corp is the only company in the world capable of producing such models and is actively working with leading FE software companies and medical researchers to develop the application further.

22. Additional Capabilities
Z Corp technology also offers a few other interesting capabilities that are worth noting.

23. Model Labeling
Using Z Corp.’s ZPrint software, surfaces can be labeled to mark particular areas of interest on the 3D model
Label text can be raised (or colored on the Z®406 and Z810 Printers)
The first one is labeling. All Z Corp models can be labeled directly in our proprietary ZPrint software. Labels can placed on the models in practically any location to assign a patient name to the model or even point out a specific surgical instruction. Customers that own our full color machines, the Z406 and Z810 Printers, can create these labels in any color they like to really insure the label stands out.
As you see in this photo here, our raised text labels can actually wrap along the contour of the models surface.

24. Precision Fixtures
Z Corp. models can be accompanied with precise fixtures to enable measurements and protect models with complex cavities
Another great feature within our ZPrint software is the ability to create precision fixtures or cradles for parts. This comes in particularly useful when building delicate parts like this one shown above which happens to be of a vascular tumor captured with an MRI. Physicians will find these fixtures useful when seeking to display models, protect them during transport or even make a few measurements of difficult to reach cavities.
Vascular tumor captured with an MRI

25. Technical Requirements
CT and MRI data in DICOM 3.0 format
0.5mm – 3mm slices
Mimics™ imaging software (Materialise)
Z Corp. 3D Printer
ZPrinter™310
Z406 Color 3D Printer
Z810 Large Format, Color 3D Printer
The real benefit of our system is that its truly simple. In fact, using a simple software solution, virtually all CT and MRI data can be formatted for printing on any of our 3D Printers. All that’s required is for the surgeon to specify to the radiologist that the images be taken with 0.5mm – 3mm slice cuts and saved in DiCom 3.0 format. The Dicom data is then saved on disk and imported into Mimics software (developed by Materialise) where it can then be analyzed and manipulated prior to being printing imported into Z Corp’s proprietary ZPrint software and then Printed. Any of Z Corp’s 3D Printers can build medical models by following these simple requirements.

26. Z Corp. Advantages vs. Legacy Technology
Cost
Z Corp. models are the lowest cost in the RP world
$1 - $2 per cubic inch
Speed
Critical trauma data can be captured and transformed into 3D models in hours
Build rate is 1” – 2” vertical inches per hour
Complex Geometries
No support structures permit the most detailed, delicate models with complex cavities to be built and easily post-processed
Material Properties
Models can be sawed, drilled, scribed, painted and bonded very simply
I’m sure that many of you are somewhat familiar with Rapid Prototyping technology since it has been used in the medical industry for nearly 15 years. However, its important to note that Z Corp technology is very different from the traditional methods many of you may have seen or even used on occasion for extremely complex cases.
Perhaps the most important point to communicate is cost. Both the cost of our equipment and the cost of our models. For under $50K (including Mimics software), and a couple hundred dollars per model, our technology is by far the lowest cost rapid prototyping solution in the market today. MAKING Z CORP. Our models cost about $1.50 per cubic inch.
Another very important attribute of our technology is speed. Z Corp printers are the fastest rapid prototyping machines in the world by a significant factor. Our build rate is between 1 and 2 vertical inches per hour, depending on the material set being used. The beauty of this is that it fits wonderfully into applications that arise from trauma cases. Its not uncommon for surgeons to receive a trauma case and then a few hours later, be holding the actual 3D model of the patient’s data in hand.
As far as complex geometries are concerned, there’s not an object we cant build. As a direct result from the means in which our models are build, all loose powder can be quickly and easily removed from any model, enabling the most complex cavities within bony structures to be prepared for observation and measurement.
Finally, since all of our models are made from plaster powder, they exhibit the look, feel and surface finish of bone. They can easily be marked, labeled, sawed and drilled to point out specific areas of interest as well as select the correct instrumentation and pre-operatively rehearse surgical techniques.

27. Z Corp. Advantages vs. Legacy Technology
Simplicity of Use
Z Corp. 3D Printers and software enable users to be fully trained in 2 days
Full Color Capabilities
Z Corp. models can be printed in millions of colors to communicate FEA (finite element analysis), bone density and tumor location data
Office Friendly
Z Corp. 3D Printers are simple to operate in any office environment and require minimal space
There are three more advantages to our technology within the medical market.
The technology is very simple to use. In as little time as two days, virtually anyone, from the surgeon to the technician can learn the techniques necessary to produce any model.
Our color capabilities are unmatched by our competition. As you are well aware, Z Corporation 3D printers are the only 3D rapid prototyping systems in the world today capable of printing millions of colors. This is specifically ideal for those seeking to perform FE analysis of the affects of compressive stress and impact on bone. Also, another great example is measuring bone density, particularly helpful in determining where to cut, drill and place hardware. Finally, its also quite helpful in communicating the location of tumors.
Finally, Z Corp printers are office friendly. There quiet, non-hazardous and have small footprints, which makes them fit easily into almost any room in a clinic, hospital or laboratory setting.

28. Value Delivered
Z Corp. 3D models deliver accurate information rapidly to enable faster, less costly surgical procedures
Pre-contoured surgical implants are positioned easier, more precisely and minimize the likelihood of hardware complications
Communication between individuals, physicians and patients alike, is simplified and easily shared
Before we close today’s presentation, I would just like to summarize the value delivered by our technology.
Read slide.

29. Reimbursement
Several U.S. surgeons have informed Z Corp. about the following CPT codes that can be used to obtain reimbursement funds for 3DP models.
CPT code was recently created as an adjunct to CT/MRI codes to cover “printed holography” with modifier 22 (unusual procedural service)
Z Corp. has been told by the AMA that the additional codes listed below can also be used to identify what our models are used for. These codes are all now used for making custom equipment/devices for treatment, planning, and simulation. These fall within the family of codes. They are 77332, 77333, Each code essentially covers components of varying degrees of complexity.

30. Maxillo-facial and Orthopaedic Surgery References
“Simply stated, our Z Corp. models are improving patient outcomes with 3D, computer aided precision.”
Dr. Jon Wagner and Dr. George Brown
University of New Mexico
Health Science Center
Albuquerque, New Mexico
Finally, we know its very common to want to speak first hand with a surgeon who is expert in the use of the technology. Both of these surgeons, Dr. Jon Wagner (left-Maxillo-facial surgery) and Dr. George Brown (right-orthopaedic surgery) have plenty of experience with Z Corp models and are very willing to share their successes to their peers within the medical profession.