J Oral Maxillofac Surg

64:1023-1029, 2006

Correlating Facial Fractures and

Cranial Injuries
Biju Pappachan, MDS,* and Mohan Alexander, MDS

Purpose: This study retrospectively evaluated individuals with traumatic injuries from different mech-
anisms and tried to determine if there is any relationship between various isolated or combined fractures
of facial skeleton and cranial injuries.
Materials and Methods: We retrospectively studied hospital charts of all patients who reported to the
trauma center at Kasturba Hospital in Manipal with facial fractures and suspected cranial injuries during
a 5-year period (January 1, 1995 to December 31, 1999). These patients were admitted to the Department
of Neurosurgery or the Maxillofacial Unit of Kasturba Hospital, Manipal. The complete medical record of
each patient was reviewed, recording the following in a standard format: age, gender, cause of injury,
type of facial fractures, type of cranial bone fracture, concussion, intracranial injury, cerebrospinal fluid
(CSF) rhinorrhea, CSF otorrhea, and the Glasgow coma scale.
Results: The study data were collected as part of retrospective analysis. A total of 12,329 patients
reported to the trauma center of the study hospital during a 5-year period with various injuries. A total
of 772 patients had facial fractures (6%). A total of 108 patients with a combination of cranial injuries and
facial fractures were identified within this group (14%). Gender predilection was seen to favor males
(90%) more than females (10%). The ratio was seen to be nearly 9:1. The ages of the patients ranged from
7 to 70 years with mean age being 32 years (standard deviation [SD] 12). Central midfacial bone
involvement was found to be more commonly associated with head injury.
Conclusions: There is a correlation between midfacial injuries and CNS trauma. A more exhaustive
multicentric case-control study with a larger sample and additional parameters will be essential to reach
definite conclusions regarding the spectrum of head injuries associated with facial fractures.
2006 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 64:1023-1029, 2006

Maxillofacial injuries traditionally have been treated
as a separate entity, but clinical research has tried to
establish a correlation between them and concomi-
tant spinal injuries.1-4 The closeness of these bones to
the cranium would suggest that there are chances of
cranial injuries also occurring simultaneously, and ex-
cept for a few studies, there is a general dearth of data
trying to establish a correlation between them.5-7
In our study, we retrospectively evaluated individ-
uals with traumatic injuries from different mecha-
nisms and tried to find if there is any relationship
*Reader, Department of Maxillofacial Surgery, Sharad Pawar Den-
tal College, Radhika Meghe Memorial Medical Trust, Sawangi
(Meghe), Wardha, Maharashtra, India.
Professor, Oral and Maxillofacial Surgery, Mahatma Gandhi Den-
tal College, Pondicherry, India.
Address correspondence and reprint requests to Dr Pappachan:
c/o Shri Kedar, Snehal Nagar, Wardha, Maharashtra, India; e-mail:
biju_pappachan@yahoo.com
2006 American Association of Oral and Maxillofacial Surgeons
0278-2391/06/6407-0006$32.00/0
doi:10.1016/j.joms.2006.03.021
between various isolated or combined fractures of
facial skeleton and cranial injuries.
Materials and Methods
We retrospectively studied hospital charts of all
patients who reported to the trauma center in Kas-
turba Hospital, Manipal, with facial fractures and sus-
pected cranial injuries during a 5-year period (January
1, 1995 to December 31, 1999). These patients were
admitted to the Department of Neurosurgery or the
Maxillofacial Unit of Kasturba Hospital, Manipal. The
complete medical record of each patient was re-
viewed, recording the following in a standard format:
age, gender, cause of injury, type of facial fractures,
type of cranial bone fracture, concussion, intracranial
injury, cerebrospinal fluid (CSF) rhinorrhea, CSF otor-
rhea, and the Glasgow coma scale.
Four categories of patients with facial fractures
were excluded including:
1. Patients who, due to serious general conditions
after severe injuries, an adequate clinical and

1023
1024
FIGURE 1. Distribution of facial bone fractures.
Pappachan and Alexander. Correlating Facial Fractures and Cranial Injuries. J Oral Maxillofac Surg 2006.
radiographic investigation was not possible and
often not desired.
2. Patients with solitary fractures of the alveolar
process (inferior or superior) or pure dental
injuries (subluxation, luxation, avulsion).
3. Patients with nasal bone fractures.
4. Patients with fractures who were treated as
outpatients.
Facial injury was defined as fractures of the maxilla
at Le Fort I, Le Fort II, or Le Fort III level.8 Maxillary
and palatine bones were considered as 1 unit. Frac-
tures of the mandible at angle, body, condyle coro-
noid, symphysis, parasymphysis, and ramus were con-
sidered separately. Fractures of the zygoma and orbit
were considered as a single unit. Head injuries were
classified into 3 groups:
1. Cranial bone fractures: frontal, temporal, sphe-
noid, parietal, occipital, and a combination of
these.
2. Concussion.
3. Intracranial injuries: broadly divided into cere-
bral contusion; cerebral laceration and subdural,
subarachnoid, and extradural hemorrhage
(which meant bleeding into these spaces).
The medical records were also examined for CSF
rhinorrhea with head injuries, when CSF leak was
present through nose; and CSF otorrhea, when CSF
leak was present through ear.
Teasdale and Jeanett9 suggested the Glasgow coma
scale (GCS) be used as a method of neurologic eval-
uation in head injury patients. The GCS denotes the
severity of injury, and the summation of 3 categories
(best motor response, best verbal response, and best
CORRELATING FACIAL FRACTURES AND CRANIAL INJURIES
eye opening response) gives a total score ranging
from 3 (worst) to 15 (best).
STATISTICAL ANALYSIS
Categorical data were analyzed by the 2 test. Con-
tinuous variables were analyzed by a Students t test.
P values less than .05 were considered statistically
significant. The statistical package SPSS/PC was
used for all analysis (SPSS, Inc, Chicago, IL).10
Results
A total of 12,329 patients reported to the trauma
center of the study hospital during the 5-year period
with various injuries. A total of 772 patients had facial
fractures (6%).
One hundred and eight patients with a combina-
tion of cranial injuries and facial fractures were iden-
tified within this group (14%). Gender predilection
was seen to favor males (90%) more than females
(10%). The ratio was nearly 9:1. The ages of the
patients ranged from 7 years to 70 years with the
mean age being 32 years (standard deviation 12).
Motor vehicle accidents were the most common
cause of injury (55%), followed by motorcycle acci-
dents (25%), assaults (8%), falls (6%), and sports (5%).
There were 130 facial fractures (when each combina-
tion fracture was also considered as a single unit). The
facial bone fracture that predominated in the group was
zygoma fracture (30%) followed by Le Fort II (8.46%),
mandibular parasymphysis and angle (5.38% each), man-
dibular body and symphysis (4.62% each), mandibular
condyle (1.54%) and Le Fort I and Le Fort III (0.77%
each) (Fig 1). In combination facial bone fractures, com-
binations of maxilla/zygoma and maxilla/mandible/zy-
PAPPACHAN AND ALEXANDER 1025

FIGURE 2. Distribution of cranial bone fractures.

Pappachan and Alexander. Correlating Facial Fractures and Cranial Injuries. J Oral Maxillofac Surg 2006.

goma were seen with equal frequency (9.23%) followed
by mandible/zygoma (6.15%).
The cranial bone most frequently fractured was the
frontal bone (37%), followed by a combination of
cranial bones (24%), the temporal bone (18%), sphe-
noid (18%), occipital (3%), and parietal (1%) (Fig 2).
The neurologic injury most commonly seen was
concussion (47.27%). In intracranial injuries, cerebral
contusion predominated (26.36%), followed by sub-
arachnoid, subdural, and extradural hemorrhage with
equal frequency (2.73% each), and cerebral laceration
(0.91%). Cerebrospinal fluid rhinorrhea was seen
more frequently (10.91%), than CSF otorrhea (6.36%)
(Fig 3).
Some of the categories of injuries (home injury,
coronoid, and ramus fracture) had no patients, and
they were subsequently excluded from statistical anal-
ysis. There were also categories of injuries that, when
compared with other injuries, contained too few pa-
tients to allow an accurate statistical comparison. For
the group that contained enough patients, a 2 test
was done to find if any significant correlation existed
between facial fracture and cranial injuries.
In maxillary fractures, isolated Le Fort I fracture had
significant association with frontal bone fracture (P
.035). It had no association, however, with other
cranial bone fractures (temporal, sphenoid, parietal,
occipital, or combinations). It was also not associated
with any neurologic injury (cerebral concussion, in-
tracranial injury) or CSF rhinorrhea and CSF otorrhea.
Isolated Le Fort II fracture was not associated with
any of the isolated cranial bone fracture but had

FIGURE 3. Distribution of neurologic injuries.

Pappachan and Alexander. Correlating Facial Fractures and Cranial Injuries. J Oral Maxillofac Surg 2006.
1026
significant association with combinations of cranial
bone fractures (P .008). It was also significantly
associated with intracranial injury cerebral laceration
(P .002). It was not, however, related to concus-
sion, other intracranial injuries (cerebral contusion,
subarachnoid, subdural and extradural hemorrhage),
or CSF rhinorrhea and CSF otorrhea. Isolated Le Fort
III fracture also had no association with any of the
isolated cranial bone fracture, but it was significantly
associated with combinations of cranial bone frac-
tures (P .006). It was also associated significantly
with CSF rhinorrhea (P .004). It was not, however,
associated with concussion, intracranial injury, or CSF
otorrhea.
Zygoma fracture had a significant association with
frontal bone fracture (P .013). It was not related to
other cranial bone fractures, neurologic injuries, or
CSF rhinorrhea and CSF otorrhea.
In mandibular fractures, condylar fracture had sig-
nificant association with temporal bone fracture (P
.04) and CSF otorrhea (P .01). Symphysis fracture
was associated significantly with occipital bone frac-
ture (P .005). They had no significant association
with other cranial bone fractures, neurologic injury,
or CSF rhinorrhea. Angle, body, and parasymphysis
fracture had no association with any cranial bone
fractures, neurologic injuries, or CSF rhinorrhea and
CSF otorrhea.
In combination fractures, combination of maxilla/
mandible/zygoma fractures had significant association
with sphenoid bone fractures (P .0002). Maxilla/
zygoma fractures had significant association with pa-
rietal bone fracture (P .004). They were not asso-
ciated with other cranial bone fractures, neurologic
injury, or CSF rhinorrhea and CSF otorrhea. Combina-
tions of mandible/zygoma were significantly associ-
ated with CSF otorrhea (P .02), but had no associ-
ation with any cranial bone fracture, neurologic
injury, or CSF rhinorrhea.
Statistical comparison of various facial fractures and
cranial injuries with severity of head injury were as-
sessed by Students t test. In facial bone fractures,
head injury was more severe in the presence of max-
illa and mandible fractures (P .01 and .03, respec-
tively). Head injury was less severe in the presence of
zygoma and maxilla/zygoma fractures (P .03 and
.00, respectively). Mandible/zygoma and maxilla/man-
dible/zygoma fractures had no significant difference
in the severity of head injury.
None of the cranial bone fractures had any signifi-
cant difference (P .05) with the severity of head
injury.
Concussion and intracranial injury had significant
difference in neurologic injury. In the cases of con-
cussion, the head injury was less severe, whereas in
CORRELATING FACIAL FRACTURES AND CRANIAL INJURIES
cases of intracranial injury, the head injury was more
severe.
No significant differences were noted with severity
of head injury in patients with CSF rhinorrhea or CSF
otorrhea.
Discussion
It has been proposed that the face protects the
brain from injury the way an airbag protects the chest
in a motor vehicle crash. Whether or not cranial
injuries can be correlated with facial fractures is an
important question with clinical implications. Multi-
ple origins and potentially significant confounding
variables make accurate assessment of the association
between traumatic head injury and facial fractures
difficult.11
Several studies describing a large series of facial
fractures have been reported.12,13 There is, however,
a general lack of literature, specifically with regard to
maxillofacial surgery pertaining to associated injuries
in general, and head injuries in particular (Table 1).5-7
In the study by Haug et al,5 it was found that
approximately one third of patients with facial frac-
tures had some form of neurologic injury. Although at
first it was thought that this incidence was high, a
thorough review of literature indicated that the fre-
quency of neurologic injury associated with facial
fracture was as high as 76%.2,13-17 Those studies, how-
ever, described neurologic injury in general terms
rather than by specific injury. In our study we found
that the frequency of cranial injury associated with
facial fracture was 14%. Motor vehicle accidents
(MVA) were the most frequent cause of combined
cranial and facial injury (55%). This finding is similar
to other studies.14,18-20 Haug et al5,7 found MVA as the
most frequent cause (64% to 91%), but they made a
note that this was not the case when they studied
facial fracture alone (43%). The use of restraints in
automobiles may contribute to a striking reduction of
road traffic accidents in the Western world. At the
same time there is an increasing influence of violence
and sports in fractures of facial skeleton.21,22 In India,
road traffic accidents seem to take precedence over
any other modality of injury due to bad roads and
poor traffic regulation compliance.
The literature shows associated skull fractures in
varied ranges, with several studies reporting 19% as-
sociated skull fractures.12,15,23-25 In all of these stud-
ies, however, skull fractures were addressed gener-
ally. Unger et al26 found a higher frequency of
sphenoid bone fractures in patients with craniofacial
fractures (70%), than in patients with complex facial
fractures. Slupchynskyj et al27 found that skull base
fractures were increased significantly in orbital wall/
rim fractures (36%), in contrast to maxillary/zygo-
PAPPACHAN AND ALEXANDER 1027

Table 1. LITERATURE REVIEW SHOWING ASSOCIATION OF FACIAL FRACTURES AND CRANIAL INJURIES

Number of Gender
Facial Skull Fracture Predilection Facial Bone
Fractures Head Injury % % Etiology (%) (%) Fractured (%)

Dawson and Fordyce 190 25 19 MCA (32) LF II, LF III (34)

(1953)23
Hueston and Cook (1956)31 990 50 MVA (45)
Schultz (1967)14 1,042 (Neck)54 9 MVA (54)
Rowe and Killey (1968)12 1,000 1.9 MVA (38.9) Male (81.5) Mandible (53.5)
Morgan et al (1972)15 300 57 19
Turvey (1977)16 593 Mid-face 5 MVA (46) M (75) Zygoma (69)
fracture
Van Hoof (1977)32 47 RTA M ()
Luce et al (1979)18 1,020 MVA (65) M:F (3:1)
Adekeye (1980)17 1,447 15.96 MVA (14.99) M:F (16.9:1) Mandible (62.19)
Davidoff (1988)19 200 55 RTA (52) M (73)
Sinclair (1988)3 168 85 Maxilla (44)
Haug (1990)5 402 Head injury MVA, M () Mandible:zygoma:
more Assaults maxilla (6:2:1)
common more
Brandt et al (1991)20 114 38 MVA (84)
Hayter (1991)33 50 86 M (82)
Lim et al (1993)34 839 5.4 Majority skull Assault with Maxilla (73)
fractures head injury
(51.2)
RTA (73)
Chang et al (1994)29 703 Central 37.1 MCA (76.8)
craniofacial
fracture
Haug et al (1994)7 882 4.4 MVA (64) M (85)
Ugboko (1998)30 442 5.7 Combined 5.7 Combined RTA (72) M Mandible (64)
Keenan et al (1999)11 81 10-fold
association
Abbreviations: F, female; M, male; MCA, motorcycle accident; MVA, motor vehicle accident; RTA, road traffic accident.
Pappachan and Alexander. Correlating Facial Fractures and Cranial Injuries. J Oral Maxillofac Surg 2006.

matic (29.4%) and mandible (4%). In our study, frontal
bone (37.04%) was the cranial bone fractured most
frequently followed by combination (24.07%) and
temporal bone (18.52%). This was in contrast to the
study of Haug et al7 where frontal (38%), sphenoid
(24%), and temporal fractures (22%) were encoun-
tered more frequently.
In neurologic injuries, various studies show concus-
sion to be associated more frequently with facial frac-
tures.6,11,19,21 In intracranial injury, cerebral contu-
sion was seen more frequently.6 In a case-control
study, Keenan et al11 found more concussion (9%)
than intracranial injury (4%). Our study group also
had concussion (47.27%) associated more frequently
with facial fractures. In intracranial injury, cerebral
contusion predominated (26.36%).
Lee et al28 reported that facial fractures are associ-
ated with a decreased risk of traumatic brain injury.
They theorized that the facial bones act as a protec-
tive cushion for the brain to explain why injuries that
crush the facial bones frequently cause no apparent
brain damage. Davidoff et al,19 however, found facial
fractures to be highly associated with traumatic brain
injury. Recently, Keenan et al11 showed that there is
no evidence that facial fracture helps prevent trau-
matic brain injury. They found that risk of intracranial
injury in those with facial injuries increased almost
10-fold, and the risk for all brain injuries, including
concussion, was doubled. Chang et al29 stated that in
central craniofacial fractures, the maxilla is not only
important for functional, physiologic, and esthetic
reasons, but with other bones of the central area, it
forms a structure capable of absorbing considerable
impact energy, thus protecting the brain from direct
collision. They concluded that there should be a di-
rect correlation between the severity of maxillary
fracture (in the central craniofacial) and that of the
initial head injury.
Zygoma fractures were only associated with frontal
bone fractures, in contrast to Haug et al7 who found
zygoma fractures to be associated frequently with
fractures of cranial bones joined by sutural attach-
ment (frontal, sphenoid, and temporal). They refuted
the theory that facial bone acts as a cushion to protect
1028
the cranium and its contents. They stressed that the
midfacial bones transmit the force of impact directly
to the cranium.
In mandibular fractures, condylar fractures had sig-
nificant association with temporal bone fracture and
CSF otorrhea. Symphysis fractures were associated
significantly with occipital bone fractures. However,
other fractures of mandible-angle, body, and parasym-
physis fractures had no association with any cranial
injury. This is in contrast to other authors, who have
found significant association of mandibular fractures
with cranial injury.3,5,6,30 Haug et al6 found mandibu-
lar fractures to be associated more frequently with
closed head injuries. They found no association be-
tween mandibular fractures and cranial fractures.
In combination facial bone fractures, maxilla/zy-
goma fractures only had associations with parietal
bone fracture. This was in contrast to the observation
by Haug et al6,7 that midfacial fractures had more than
twice the chance of sustaining cranial fractures and
neurologic injury. Mandible/zygoma combinations in
our study group were associated with CSF otorrhea.
When maxilla/mandible/zygoma fractures occurred
they were only associated with sphenoid fractures.
This may mean that even though the forces were
great enough to cause these multiple fractures of the
face, a part of it could be dissipated so that less
serious cranial injury would be sustained.
When we considered severity of injury with facial
fractures, we found that isolated maxillary and iso-
lated mandibular fractures correlated with more se-
vere head injury. We also found that whenever iso-
lated zygomatic fracture or combinations of maxilla/
zygomatic fractures occurred, the head injury was less
severe, whereas Haug et al6 found most severe intra-
cranial injuries with combination of mandible/zy-
goma or maxilla/zygoma fractures. They found no
relationship, however, between severity of head in-
jury and either the mechanism of injury, the cranial
bone(s) fractured, or the facial bone(s) fractured. We
found no relationship between cranial bone fracture
and severity of head injury. When considering neuro-
logic injuries with the presence of concussion, how-
ever, head injury was less severe and in the presence
of intracranial injury, head injury was more severe.
Although our study data was comprised of fewer
patients, when considering the individual facial bones
we were able to single out the central midfacial bone
to be associated more commonly with head injury. A
more exhaustive multicentric case-control study with
larger sample and additional parameters will be essen-
tial to reach definite conclusions regarding the spec-
trum of head injuries associated with facial fractures.
Such a correlation might help in better diagnosis of
unsuspected cranial injuries, thereby resulting in de-
CORRELATING FACIAL FRACTURES AND CRANIAL INJURIES
creasing the morbidity and mortality associated with
craniofacial trauma.
Acknowledgments
The authors thank Dr S. Nair KMC Manipal for help with the
statistics, Mr Acharya MCODS for help with the figures, and the
Manipal Academy of Higher Education for help rendered with the
study.
References
1. Bertolami CN, Kaban LB: Chin trauma: A clue to associated
mandibular and cervical spine injury. Oral Surg 53:122, 1982
2. McCabe JB, Angelos MG: Injury to head and face in patients
with cervical spine injury. Am J Emerg Med 2:333, 1984
3. Sinclair D, Schwartz M, Gruss J, et al: A retrospective review of
the relationship between facial fractures, head injuries, and
cervical spine injuries. J Emerg Med 6:109, 1988
4. Haug RH, Wible RT, Likavec MJ, et al: Cervical spine frac-
tures and maxillofacial trauma. J Oral Maxillofacial Surg
49:725, 1991
5. Haug RH, Prather J, Indresano AT: An epidemiologic survey of
facial fractures and concomitant injury. J Oral Maxillofacial
Surg 48:926, 1990
6. Haug RH, Savage JD, Likavec MJ, et al: A review of 100 closed
head injuries associated with facial fractures. J Oral Maxillofa-
cial Surg 50:218, 1992
7. Haug RH, Adams MJ, Conforti PJ, et al: Cranial fractures asso-
ciated with facial fractures. J Oral Maxillofacial Surg 52:729,
1994
8. Tessier P. The classic reprint: Experimental study of fractures
of the upper jaw. 3. Rene Le Fort, MD, Lille, France. Plast
Reconstr Surg 50:600, 1972
9. Teasdale G, Jeanett B: Assessment of coma and impaired con-
sciousness, a practical scale. Lancet 2:81, 1974
10. Norusis MJ: SPSS for the IBM PC/AT, version 1.0 (base manual
and advanced statistics). SPSS Inc, Chicago, 1986
11. Keenan HT, Brundage SI, Thompson DC; et al: Does the face
protect the brain? A case-control study of traumatic brain injury
and facial fractures. Arch Surg 134:14, 1999
12. Rowe NL, Killey HC: Fractures of the facial skeleton. Living-
stone, London, 1968, p 857
13. Murray JF, Hall HC: Fractures of mandible in motor vehicle
accidents. Clin Plast Surg 2:131, 1975
14. Schultz RC: Facial injuries from automobile accidents: A study
of 400 consecutive cases. Plast Reconstr Surg 40:415, 1967
15. Morgan BDG, Maden DK, Bergerot JPC: Fractures of the middle
third of face: A review of 300 cases. Br J Plast Surg 25:147, 1972
16. Turvey TA, Midfacial fractures: A retrospective analysis of 593
cases. J Oral Surg 35:887, 1977
17. Adekeye EO: The pattern of fractures of the facial skeleton in
Kaduna, Nigeria. Oral Surg Oral Med Oral Pathol 49:491, 1980
18. Luce EA, Tubb TD, Moore AM: Review of 1000 major facial
fractures and associated injury. Plast Reconstr Surg 63:26,
1979
19. Davidoff G, Jakubowski M, Thomas D, et al: The spectrum of
closed head injuries in facial trauma victims: Incidence and
impact. Ann Emerg Med 17:6, 1988
20. Brandt KE, Burruss GL, Hickerson WL, et al: The manage-
ment of midface fractures with intracranial injury. Injury
31:15, 1991
21. Van Beek GJ, Merkx CA: Changes in the pattern of fractures of
the maxillofacial skeleton. Int J Oral Maxillofac Surg 28:424,
1999
22. Beck RA, Blakeslee DB: The changing picture of facial frac-
tures. Arch Otolaryngol Head Neck Surg 115:826, 1989
23. Dawson RLG, Fordyce GL: Complex fractures of middle third
face and their early treatment. Br J Surg 41:254, 1953
24. O Sullivan ST, Snyder BJ, Moore MH, et al: Outcome measure-
ment of treatment of maxillary fractures: A prospective analysis
of 100 consecutive cases. Br J Plast Surg 52:519, 1999
PAPPACHAN AND ALEXANDER
25. Dawson RLG: The priorities and emergency treatment of mul-
tiple injuries including maxillofacial trauma. Br Dent J 113:345,
1962
26. Unger JM, Gentry LR, Grossman JE: Sphenoid fractures: prev-
alence, sites and significance. Radiology 175:175, 1990
27. Slupchynskyj OS, Berkower AS, Byrne DW, et al: Association of
skull base and facial fractures. Laryngoscope 102:1247, 1992
28. Lee KF, Wagner LK, Lee YE, et al: The impact absorbing effects
of facial fractures in closed head injury. J Neurosurg 66:542,
1987
29. Chang CJ, Chen YR, Noordhoff MS, et al: Maxillary involvement
in central craniofacial fractures with associated head injuries.
J Trauma 37:807, 1994
1029
30. Ugboko VI, Odusanya SA, Fagade OO: Maxillofacial fractures in
a semi-urban Nigerian teaching hospital. A review of 442 cases.
Int J Oral Maxillofac Surg 27:286, 1998
31. Hueston JT, Cook RJ: Incidence of the major fracture patterns
in the face. Med J Aust 2:141, 1956
32. Van hoof RF, Merkx CA, Stekelenburg EC: The different pat-
terns of fractures of facial skeleton in four European countries.
Int J Oral Surg 6:3, 1977
33. Hayter JP, Ward AJ, Smith EJ: Maxillofacial trauma in severely
injured patients. Br J Oral Maxillofac Surg 29:370, 1991
34. Lim LH, Lam LK, Moore MH, et al: Associated injuries in
facial fractures: Review of 839 patients. Br J Plast Surg
46:635, 1993