Orthodontics correction of malposed teeth creates gingival contour s that are more conductive to periodontal health . Lower incisor may be extracted to correct crowding ,provided the extractions creates sufficient space for proper alignment of the of the remaining teeth and ad anterior guidance can be established in extensive movements . in judicious extraction of mandibular incisors although it corrects localized crowding ,may result in an increase in the over jet and create undesirable periodontal and aesthetic sequel consultation with an orthodontist is recommended before a lower incisor is extracted to eliminate crowding

1. Haemorrhage

2. Hemorrhage
 Hemorrhage ( hemorrhage ) denotes the escape of
blood from a blood vessel
Note
the word hemorrhage is synonymous bleeding

4. Classifications
BASED ON
SOURCE
OF BLLOD LOSS
BASED ON
TIME OF
OCCURENCE
BASED ON
CLINICAL SIGN
OF
HAEMORRHAGE
BASED ON
VISUALISATI
-ON OF
HAEMORRH
-AGE
ARTERIAL
VENOUS
CAPILARY
PRIMERY
SECONDARY
REACTIONARY
Petechiae
Ecchymosis
Hematoma
EXTRNAL
INTERNSL
BASED ON
VOLUMEOF
BLOOD LOSS

5.  Arterial is bright red in colour,The blood is emitted as a jet with each heartbeat.
 Venous is dark red, steady and continuous flow
 Capillary: Here bleeding is rapid and bright red.There is generalized ooze of blood

6. 2. DEPENDINGUPONTIMEOF HEMORRHAGE
 Primary Hemorrhage
It occurs at the time of trauma or
surgery.

7.  Reactionary Hemorrhage
It occurs within 24 hours of trauma or operation .of blood clot or slippage of ligature.
The precipitating factors are:
• Rise in blood pressure during recovery from shock.
• Rise in venous pressure due to coughing, vomiting, etc.

8.  Secondary Hemorrhage
It occurs after 7-14 days of trauma or
operation. It is due to infection and
sloughing of the vessel wall causing
moderate to severe bleeding and
pericepated by factors such as infection
pressure necrosis such ( drain or
malignancy )

9.  External Hemorrhage
When the bleeding is revealed
and seen outside, e.g. epistaxis,
bleeding from scalp wound,
bleeding during surgery.
3:DEPENDING UPON SOURCEOF BLEEDING

10.  Internal Hemorrhage
When the bleeding is
concealed and not seen
outside, e.g. intracranial
hematoma
4: DEPENDINGUPON SOURCEOF BLEEDING

11.  Petechiae
 Ecchymosis
 Hematoma

12. 6.DEPENDING UPON VOLUME OF BLOOD LOSS
 Mild Hemorrhage ( class I )
 Moderate Hemorrhage ( class II & III )
 Severe Hemorrhage ( class IV )

13. 7. DEPENDING UPON SPEED OF BLOOD LOSS
 Acute hemorrhage: It is sudden, severe hemorrhage after trauma,
surgery.
 Chronic hemorrhage: It is slow bleeding that is small in quantity and continues
for a long time, e.g. bleeding piles, bleeding peptic ulcer.
 Acute on chronic hemorrhage: It is more dangerous as the bleeding occurs in
individuals who are already hypoxic, which may get worsened faster.
8.DEPENDING UPON SPEED OF possible intervention:
 Surgical hemorrhage : can be corrected by surgical intervention.
 Nonsurgical hemorrhage : diffuse ooze due to coagulation abnormalities
and DIC.

14. CAUSES OF HAEMORRHAGE
1. Trauma
2. Infections
3. Local irritant
4. Congenital malformations
5. Surgical
6. Due to abnormalities in clotting factors
a clotting factor deficiencies
- hereditary
- anticoagulation therapy
- liver disease
b dysfunction of clotting
7. Due to abnormalities in platelets
a deficiencies
b excess
c dysfunction
8. Due to systemic disease

15. Pathophysiology of Hemorrhage
Bleeding
↓
Hypovolemic
↓
Low cardiac output
↓
Tachycardia and vasoconstriction of peripheral to maintain perfusion of vital
organs
↓
Hypoxia
↓
Activation of cardiac depressants

16. ↓
Anaerobic metabolism
↓
Hyponatraemic, hyperkalaemic, hypocalcaemic metabolic acidosis
↓
Lysosomes of cell get lysed releasing powerful enzymes
which is lethal to cell itself
↓
SICK CELL SYNDROME
Platelets and coagulants are activated leading to formation of
small clots DIC and further bleeding.
↓
Progressive haemodilution leading to total circulatory Failure.

17. Clinical Features of Haemorrhage
 Pallor, thirsty, cyanosis.
 Tachycardia, tachypnoea.
 Air hunger.
 Cold clammy skin due to vasoconstriction.
 Dry face, dry mouth and goose skin appearance (due to
contraction of arrector pilorum).
 Rapid thready pulse, hypotension.
 Oliguria.
 Features related to specific causes.

18. Hematological Investigation
1. Complete blood count
2. Activation partial thromboplastin time (APTT)
3. Prothrombin time & international normalised
4. Thrombin time
5. Platelet count
6. Serum for blood grouping & cross matching
7. FactorVII clotting activity
8. vWF antigen
9. Ristocetin cofactor activity
10. vWF multimers
11. Platelet aggregation tests

19. CLINICAL FEATURESOF ACUTE BLOOD LOSS
1. Increasing pallor
2. Increasing pulse rate
3. Restlessness
4. Air hunger
5. Cold clammy skin
6. Thirst
7. Tinnitus
8. Blindness
9. Blood pressure – normal / slightly raised
10. Urinary output – reduced
11. Haemoglobin level – may fall after some hours

35. ThankYou