Correlation of Pattern and Presentation of Maxillofacial Injuries with Seatbelt Law Compliance in Saudi Arabia

Introduction

Injuries to the soft and hard tissues of the facial region are called maxillofacial injuries, and they have a significant impact on a patient’s quality of life [1,2]. The causes of these injuries are multifactorial, and vary with the country or region but range from civil violence, sports injuries, falls, industrial accidents, and road traffic accidents [3–5]. Road traffic accidents cause significant morbidity and mortality in Saudi Arabia and globally [6–12]. Among patients injured in road traffic accidents, young and middle aged men, who represent a significant portion of the societal workforce, are the most commonly affected group, according to the World Health Organization (WHO) [13] Overconfidence, over-speeding, substance abuse, and traffic rule violations, as well as deficient road infrastructure, are known causes of road traffic accidents [12,14–16]. The impact of road traffic accidents is enormous and has societal and environmental implications, including increased economic burden [10,16,17]. The economic and health implications of the high rate of road traffic accidents became a public health issue, necessitating a health policy shift aimed at reducing the incidence of road traffic accidents, as outlined in a 2004 WHO report [18,19].

One measure recommended was the mandatory use of a seatbelt while driving [20,21]. Compliance with seatbelt use has a significant positive impact in reducing motor vehicle injury outcomes [22–24]. Mandatory seatbelt use was introduced in Saudi Arabia in December, 2000, with strict enforcement implemented starting in 2018 via introduction of traffic cameras [9,20,25,26].

The pattern and presentation of maxillofacial injuries depends on the trauma etiology [8]. Some studies have found that mandibular fractures were more likely to result from interpersonal violence or sports injury while mid-facial fractures were more commonly associated with road traffic accidents [6,27–30]. The relatively high prevalence of road traffic accidents within the Saudi Arabian kingdom as well as the paucity of data on the rate of compliance with the seatbelt use law necessitated the need for a review of maxillofacial injuries associated with road traffic accidents in the southern region of Saudi Arabia, using a well-established center with a maxillofacial treatment facility as the reference institution. Therefore, this retrospective study aimed to evaluate 435 patients involved in road traffic accidents that resulted in maxillofacial injuries in Saudi Arabia between 2006 and 2021, and the possible relationship of these injuries to rates of seatbelt use.

Material and Methods

STATISTICAL ANALYSIS:

Descriptive statistical analysis was conducted using SPSS (version 25.0, IBM) for categorical variables, and results were expressed using frequency tables and percentages. Bivariate analysis was conducted to test the association between seatbelt use and maxillofacial injury. Where applicable, chi-square was used to assess association between variables. All tests were 2-tailed and considered significant at P value equal to or less than 0.05 (P≤0.05).

Results

SOCIAL DEMOGRAPHICS:

Out of 486 cases reviewed, 51 were excluded, leaving 435 patients (335 male, 100 female; ratio 3.35: 1). Among the patients wearing seatbelts, in the <20 age group, 13 male patients (22.4%) and 3 female patients (100%) were injured. In the age group of 21–40 years and 41–60 years, 37 (63.8%) and 8 (13.8%) men, respectively, had injuries. Therefore, overall, among the patients wearing a seatbelt, a significantly higher number of men were injured as compared with women (P=0.012).

Similarly, among the patients not wearing seatbelts, in the age group of <20 years, 75 (27.1%) male patients as compared with 39 (26.3%) female patients were injured, while in the age group of 21–40 years, 148 (53.4%) men as compared with 31 (32%) women were injured. In the age group of 41–60 years, 37 (13.4%) men but only 19 (19.6%) women who were not wearing seatbelts were injured. In the age group of >60 years, 17 (6.1%) men and 8 (8.2%) women who were not wearing seatbelts were injured. Thus, a statistically significantly higher number of men were injured as compared with women, when not wearing seatbelts (P=0.004*). A significantly higher number of men as compared with women were victims and the majority belonged to the age group of 21–40 years (Table 1).

VEHICLE OCCUPANT POSITIONS:

Table 2 shows that the majority of the patients were drivers (n=210) followed by front row passengers (n=152). The least number of victims were back row passengers (n=73). Among the drivers who were wearing seatbelts (WSB), only 1 (2.7%) woman and 36 (97.3%) men were injured. Among the drivers who were not wearing seatbelts (NWSB), a significantly higher number of men [144 (83.2%)] were injured as compared with women [29 (16.8%)], and the difference between the groups was statistically significant (P=0.027). Among the front row passengers wearing seatbelts, 18 (94.7%) male patients were injured compared with only 1 (5.3%) female patient, while among those not wearing seatbelts, 41 (30.8%) female patients and 92 (69.2%) male patients were injured. The difference between these groups was statistically significant (P=0.020). Among the back row passengers, there were 4 (80%) male patients and 1 (20%) female patient who were injured while wearing a seatbelt. In contrast, for NWSB patients, 41 (60.3%) male patients and 27 (39.7%) female patients were injured. However, the difference between the groups was not statistically significant (P>0.05). Overall, among the patients wearing and not wearing seatbelts, male patients were injured significantly more often than female patients (P<0.001).

Table 3 and Figure 1 show that maxillofacial injuries were more common among the NWSB patients than the WSB patients. Frontal injuries were higher among NWSB patients: 39 (76.5%), vs 12 (23.5%) for WSB patients, and the difference was statistically significant (P=0.037). Among patients with naso-orbito-ethmoid (NOE) injuries, 98 (87.5%) were NWSB as compared with 14 (12.5%) WSB, but the difference between the groups was not statistically significant (P>0.05). Significantly higher zygomaticomaxillary complex (ZMC) injuries were seen among the NWSB patients [139 (81.8%)], compared with the WSB patients [31 (18.2%)] (P=0.043). The Le Fort I, II, and III injuries among the NWSB patients were 173 (86.1%), 60 (85.7%), and 1 (100%), respectively, vs 28 (13.9%), 10 (14.3%), and 0 (0%) among the WSB patients, respectively, with no significant difference between the groups based on status of wearing seatbelts (P>0.05). Although a higher number of NWSB patients [191 (85.3%)] had injuries to the mandible compared with WSB patients [33 (14.7%)], the difference was not statistically significant (P>0.05).

Table 4 shows the distribution of facial traumas with associated injuries considering seatbelt use by patients involved in road traffic accidents. Among the patients with frontal injuries, for WSB patients, there were 1 (8.3%), 5 (41.7%), and 6 (50%) injuries associated with the skull, thorax, and abdomen, respectively, while NWSB patients had 11 (28.2%), 19 (48.7%), 17 (43.6%), 7 (17.9%), 4 (10.3%), and 2 (5.1%) injuries to the skull, thorax, abdomen upper limb, lower limb and neck, respectively. Among WSB patients, ZMC injuries were associated with 4 (12.9%), 1 (3.2%), 8 (25.8%), 3 (9.7%), 3 (9.7%), and 2 (6.5%) injuries to the skull, thorax, abdomen, upper limb, lower limb, and neck, respectively. Among the NWSB patients, the ZMC injuries were associated with 42 (30.2%), 41 (29.5%), 12 (8.6%), 9 (6.5%), 14 (10.1%), and 6 (4.3%) injuries to the skull, thorax, abdomen, upper limb, lower limb, and neck, respectively. Among injuries associated with NOE, among the WSB patients, there were 6 (42.9%), 6 (42.9%), 2 (14.3%), and 3 (21.4%) injuries associated with the thorax, abdomen, upper limb, and lower limb, respectively, while among the NWSB patients, there were 30 (30.6%), 38 (38.8%), 23 (23.5%), 13 (13.3%), 13 (13.3%), and 2 (2%) injuries to skull, thorax, abdomen, upper limb, lower limb, and neck, respectively (Table 4).

Table 5 shows that, considering all the maxillofacial injuries, abrasions and lacerations were seen in the majority of the NWSB patients. For WSB patients with frontal traumas, 8 (27.6%) had abrasions and 4 (18.2%) had lacerations; while among the NWSB patients, 21 (72.4%) and 18 (81.8%) had abrasions and lacerations, respectively. Although the NWSB patients had more soft-tissue injuries, the difference between the groups was not statistically significant (P>0.05). For NOE injuries, 6 (8.8%) and 8 (18.2%) WSB patients had abrasions and lacerations, respectively, while 62 (91.2%) and 36 (81.8%) NWSB patients had abrasions and lacerations, respectively, but the difference between the groups was not statistically significant (P>0.05). Regarding ZMC injuries, among WSB patients, 20 (25%) and 11 (12.2%) patients had abrasions and lacerations, respectively, while 60 (75%) and 79 (87.8%) NWSB patients had abrasions and lacerations, respectively. The difference between the groups was statistically significant (P=0.031; Table 5).

Table 6 shows that all the patients with frontal trauma, including 12 (23.5%) WSB patients and 39 (76.5%) NWSB patients, were treated by open reduction. Among the patients with NOE injuries, 14 (14%) WSB patients were treated by open reduction while 86 (86%) NWSB patients were treated by open reduction and 12 (100%) NWSB patients were treated with closed reduction. There was no statistically significant difference between the groups (P>0.05). Similarly, for ZMC injuries, 31 (18.3%) WSB patients were treated by open reduction while 138 (81.7%) NWSB patients were treated by open reduction and 1 (100%) NWSB patient was treated by closed reduction. There was no statistically significant difference between the groups (P>0.05). For Le Forte I, II, and III fractures, among WSB patients, 38 (14.1%) were treated by open reduction, while among NWSB patients, 2 (100%) were treated by closed reduction, 231 (85.9%) were treated by open reduction, and 1 (100%) was given no treatment (Table 6, Figure 2).

Discussion

More male patients were seen in our study, with a male-to-female ratio of 3.35: 1. Our finding is consistent with other studies from Saudi Arabia, Brazil, and Armenia [28,29]. However, our ratio was lower than the 6.4: 1 and 4.5: 1 ratios reported in systematic reviews of maxillofacial injuries in the Gulf Cooperation Council and Middle East and North Africa countries, respectively, and the 9: 1 ratio reported in another Saudi study [6,31–35]. In contrast to our findings, a lower male-to-female ratio was noted in some studies of road traffic accidents in developed Western countries [5,23]. The lower ratios were attributed to decreased prevalence of road traffic accidents as a result of strict enforcement of road safety policies [22,23]. Studies that found higher male-to-female ratios included studies of all maxillofacial injuries, regardless of the etiology, and were conducted on larger population sizes than ours [34,35]. The male propensity to traumatic injury has been attributed to more outdoor work, overconfidence, reckless driving, and use of recreational drugs, among others [7,30]. In addition, the higher male-to-female ratio seen in our study may also be explained by the fact that within the study period, there were still existing laws restricting women from driving until recently, when the ban on female driving was lifted [36]. Furthermore, our lower sample size as compared with other studies may also be contributory. The majority of the patients in our study were within the age group of 21–40 years, which is similar to other studies from within and outside the kingdom of Saudi Arabia [7,23,33,37].

A significant number of the patients in our study were NWSB (86%). Almost all the female patients (97%) in our study were NWSB, compared with 82.7% of the male patients. This finding is consistent with findings in a Singaporean study that reported lower compliance among women compared with men. In contrast to our findings, studies from the Western world had higher compliance rates of seatbelt usage among women [21,38]. The difference between our study and other, contradictory studies may be cultural, as suggested by Alghnam et al [9], as most women in the kingdom of Saudi Arabia are chauffeur-driven, as can be seen in our study, where only 30% of total female patients were drivers. Because they are chauffeur-driven, they may not feel the need to put on a seatbelt.

The majority of the patients in our study were male drivers while most of the female patients were front- and back-seat passengers (Table 2). Despite increased monitoring of traffic violations, with penalties imposed where applicable, since 2018, compliance is still low, as seen in our study. Our findings are similar to those from previous studies that reported low compliance rates among drivers in the kingdom of Saudi Arabia [7,9,10,39]. Some studies have attributed this low compliance rate to reasons such as youthfulness, overconfidence among youths, frequent stops by public transport drivers, and psychological illness such as anxiety and depression [7,9]. Previous reports have noted initially high compliance rates of seatbelt use among the Saudi populace with the introduction of traffic cameras, but these rates have started declining, with different rates reported across the various regions of the kingdom of Saudi Arabia [25,40]. Absence of traffic camera coverage on all roads in the kingdom may be contributory since the likelihood of receiving a traffic violation decreases in the absence of monitoring mechanisms.

In the present study, seatbelt usage had a statistically significant impact on maxillofacial injuries following road traffic accidents (P=0.027). This is similar to findings from previous studies that reported reductions in numbers and severity of maxillofacial injuries in WSB patients following road traffic accidents [6,22,23,26,29,41]. However, seatbelts, while very effective for front- and back-seat passengers, may have a limited impact on injuries to drivers [42]. Due to the presence of the steering wheel, drivers are more prone to injuries from road traffic accidents; however, the severity is reduced with seatbelt use [23,42]. Additionally, improper seatbelt usage may be associated with injuries following road traffic accidents, as seen in seatbelt syndrome cases [20].

Most maxillofacial injuries were seen in NWSB patients, with a lower number in WSB patients. Mandibular fractures were the most common fracture seen in our study, followed by Le Fort I and zygomatic complex fractures. However, using the classification of the facial skeleton into upper, middle, and lower thirds, we found mid-facial fractures to be the most common maxillofacial injuries resulting from road traffic accidents. This finding is similar to those of previous studies that reported mid-facial fractures as the most common facial injuries following road traffic accidents [4,6,22,24,27]. However, based on individual facial bone sites, our findings were similar to other studies, which reported mandible fracture as the most common maxillofacial injury following motor vehicle accidents [34,43,44]. In contrast to this finding, Aleksanyan et al reported nasal fractures (47.5%) as the most common maxillofacial injury resulting from road traffic accidents, mostly in NWSB patients, followed by injuries to the mandible (31.4%) and the zygomatic complex [33]. The increase in facial fractures among NWSB patients may be attributed to the whiplash effect associated with road traffic accidents. Contrary to this finding, Fouda Mbarga et al reported no significant difference in the risk of facial injury following road traffic accidents in WSB and NWSB patients in their meta-analysis of data from 2 studies they reviewed for facial injuries [45]. Associated bodily injuries following maxillofacial trauma due to road traffic accidents had skull injuries as the most common, followed by thoracic and abdominal injuries, while neck injuries were the least commonly seen in our study. This finding may be explained by the close proximity of facial bones to the skull. In addition, an increase in associated injuries was seen in NWSB patients, thus highlighting the mitigating impact of seatbelt usage on injury risk following road traffic accidents. Our finding is similar to findings in a 10-year retrospective review of maxillofacial injuries and seatbelt use by Mendes et al, who found that 143 of their study patients had facial trauma with associated injuries [46]. Le Fort, mandibular, and zygomatic complex fractures were the most common maxillofacial injuries they reported to be associated with other bodily injuries; we also found Le Fort, zygomatic complex, and mandibular fractures to be the maxillofacial injuries most commonly associated with bodily injuries. Whiplash phenomenon as well as seatbelt syndrome may account for some of these injuries, even though there were more injuries among the NWSB patients. Abrasion was the most common soft-tissue injury seen in our study, with a significant additional incidence of lacerations, which were largely associated with Le Fort and mandibular fractures. This finding is in contrast to previous studies in the literature that report lacerations as the most common form of soft-tissue injury following road traffic accidents [47,48]. The impact of shattered glass acting as projectiles during road traffic accidents, as well as collision with objects or vehicle parts, has been noted to account for these injuries [49]. These soft-tissue injuries were seen less in WSB patients, even though there was no statistically significant difference when compared with NWSB patients.

Open reduction was the treatment of choice for the vast majority of patients in our present study. This finding is in contrast to the findings of Aldwsari et al, who reported that the majority of their study patients were treated conservatively [6]. However, our finding is similar to other studies on treatment modalities for maxillofacial injuries following road traffic accidents [15,23]. In our study, no statistically significant difference was found between the treatments provided to the patients based on their seatbelt-wearing status or type of maxillofacial trauma.

Previous studies have shown that enforcement of mandatory seatbelt use as well as other measures taken by the government resulted in decreased incidence of road traffic accident-associated mortality as well as severity of corresponding injuries across the kingdom of Saudi Arabia [7,50]. The mortality rate from road traffic accidents decreased by 26%, with 8464 fewer injuries seen between 2019 and 2022, based on statistics from the kingdom of Saudi Arabia [17]. This finding suggests a downward trend, but a still-significant reported number of injuries and death [17]. Motor vehicles are the principal means of transportation in Saudi Arabia, with as many as 6 million cars in use, which may explain the increase in prevalence of road traffic accidents in the kingdom [35].

The retrospective nature of our study, coupled with its nature as a single institutional review, were some of the noted constraints. Furthermore, lack of identification of the vehicles involved in the accidents or type of collision, and absence of records on injury severity as well as exact type of treatment given, including duration of hospital stay, were also seen as limitations of the present study.

Conclusions

The seatbelt use compliance rate is still low within the kingdom of Saudi Arabia, as seen in our study. Injuries following road traffic accidents were seen more often among male patients and drivers, in our study. Maxillofacial injuries were seen more in patients without seatbelts. Middle-third and mandibular fractures were common among the patients seen in our study and were commonly associated with skull and abrasion injuries. Treatment options were mainly open reductions and were independent of seatbelt usage. More efforts should be put in place to encourage seatbelt usage among the populace through enlightenment programs and stricter enforcement of road safety polices. Multicenter studies on the rate of compliance with seatbelt use and maxillofacial injuries should be carried out across the kingdom of Saudi Arabia, to reach more definitive conclusions.