COVID-19 and maxillofacial trauma: are we back to where we left off?

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Fahad Al Qooz, Mohammed S. Al Olaimat, Zaid R. Alzoubi, Mohammed Opaidallah Alanazi, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5815066/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Design: This wasa single-centre cross-sectional retrospective study. Background: Facial trauma is inevitable in the field of maxillofacial surgery. Restrictive measures imposed during the pandemic increased patients’ anxiety and social awareness. Despite these changes, trauma continues through the mechanisms of falls, motor‒vehicle accidents (MVAs), alleged assaults, and other aetiologies. Objective: To identify the changes in the patterns of maxillofacial trauma and types of fractures that occurred during and after the pandemic and the impact of the pandemic on maxillofacial trauma in the Middle East. Patients & Methods: This study was conducted retrospectively at the King Hussein Medical Center, Hashemite Kingdom of Jordan, from May 2022 to May 2024. The inclusion criterion wasthe surgical repair of facial fractures during and after the COVID-19 pandemic. Patients of both sexes were included if they were under the age of 75. The exclusion criterion was the failure to fulfil the inclusion criterion. Statistical analysis was performed with IBM SPSS v29 (IBM Corp, Armonk, NY, US), with significant results indicated by a p value <0.05. Results: Patients were divided into two groups: patients in group 1 underwent surgery during the pandemic, and patients in group 2 underwent surgery after it had been declared that the pandemic was over. A total of 136 patients were included in this retrospective analysis. Fall injuries were the most common mechanism of injury in group 1, although the proportion of patients who had experienced MVAs was also high, whereas in group 2, the prevalence of MVA was twice as high as in group 1. There were statistically significant differences in the mechanism of trauma and the type of fracture between both groups, both when considered together and separately (p 0.05). Conclusion: Maxillofacial trauma can be controlled but cannot be prevented. An emphasis on educating the population about safety measures at home, in workplaces, and/or while driving is needed. Coordination between civil defence departments and hospitals playsan important role in educating the population and reducing the incidence and prevalence of trauma. Dentistry facial trauma COVID falls assault motor‒vehicle accident Introduction Following the declaration of COVID-19 as a global pandemic, the numbers performed of many maxillofacial surgical interventions declined. Given that maxillofacial surgery is a specialty that involves close contact between surgeons and patients, many restrictions were imposed that posed challenges to surgeon. The WHO declared an end to the COVID-19 pandemic on the 11th of May 2023, and changes in patient behaviour has meant that the field of maxillofacial trauma has gradually returned to normal. Owing to restrictions put in place due to the COVID-19 pandemic and the consequent changes in human behaviour, the patterns of trauma have changed. [ 1 ] Visholm et al. reported that the number of patients presenting with facial trauma drastically declined during the pandemic, citing many influencing factors. [ 2 ] The COVID-19 pandemic strongly impacted the population and patient behaviour. A 65% decrease in interpersonal violence during the lockdown was estimated. Social anxiety is one of the main reasons patients failed to seek care. [ 3 , 4 ] Stansisce et al. considered interpersonal violence to be the most prevalent cause of maxillofacial trauma, followed by MVAs. [ 4 ] Facial trauma is usually due to falls, MVAs, or assaults. The authors of other studies speculated that falls were the leading cause of facial trauma in the pre-COVID-19 and COVID-19 eras, followed by MVAs. [ 5 – 7 ] This study aimed to identify 1) the types of maxillofacial fractures observed during the COVID-19 pandemic and in the post-COVID-19 era; 2) the changes in the aetiology of maxillofacial trauma from the period during the COVID-19 pandemic to the post-pandemic period; and 3) the impact of lockdown restrictions on the specialty of maxillofacial surgery. Materials & Methods The end of the COVID pandemic was declared on the 5th of May 2023. This retrospective study was carried out at King Hussein Medical Centre, Royal Medical Services, Hashemite Kingdom of Jordan, from May 2022 to May 2024, which included one year before and one year after the declaration that the pandemic had ended. We gathered data from our theatre logbook registry. We included data from all patients who were admitted to the maxillofacial department and underwent surgical repair of facial fractures. A total of 136 patients were included in this study. The demographic data included age, sex, mechanism of trauma, and type of facial fracture. We also subdivided the aetiology of trauma into 6 main categories: motor vehicle accidents (MVAs), falls, assaults, crush injuries, gunshots, and blast injuries. This study was conducted in accordance with the Helsinki Declaration. As a prerequisite, all patients underwent computed tomographic (CT) imaging before surgical repair. The inclusion criteria were as follows: 1) maxillofacial fracture repair; 2) any mechanism of trauma, including falls, motor-vehicle accidents, assaults, crush injuries, or gunshot injuries; 3) ages less than 75 years, regardless of sex. The exclusion criterion was the failure to fulfil any of the inclusion criteria. We separated the patients into two groups. The first group of patients included those who sustained facial fractures and underwent surgical repair during the pandemic. The second group of patients underwent surgical repair after the pandemic. The types of fractures were classified, and subgroups were analysed. Mandibular fractures were categorized into para-symphyseal, symphyseal, body, angle, and subcondylar fractures. The condyles were considered a single entity outside the mandible. All other fractures were considered single entities and included the following: zygoma (ZMC), orbital floor, naso-orbito-ethmoidal (NOE), midface, frontal, and pan-facial fractures. Pan-facial fractures included fractures involving the lower, middle, and upper face. Statistical analysis was performed with IBM SPSS v29 (IBM Corp., Armonk, NY, US). Statistical significance was defined as a p value < 0.05. Variables were analysed with the chi-square test and Fisher’s test. Results A total of 136 patients were included in this study and were divided into two groups: those who underwent surgery during the COVID-19 pandemic (group 1) and those who underwent surgery after the COVID-19 pandemic (group 2). Their ages ranged from 2 to 72 years, with a mean of 33.38 years (SD +/- 15.21). Most of the trauma patients in both groups were male. Group 1 included 61 patients, with 53 males (86.9%) and 8 females (13.1%). The ages of the male patients ranged from 8 to 74 years, with a mean of 34 years. The ages of the female patients ranged from 11 to 41 years, with a mean age of 34 years. Seventy-five patients were included in group 2, including 66 males (88%) and 9 females (12%). The ages of the male patients ranged from 11 to 70 years, with a mean age of 33.6 years. The ages of the female patients ranged from 2 to 72 years, with a mean age of 28.5 years. The most common aetiology in group 1 was falls (n = 30, 49.2%), followed by motor‒vehicle accidents (n = 20, 32.8%). The most common aetiology of trauma in group 2 was MVAs (n = 50, 66.7%), followed by falls (n = 16, 21.3%). The proportions of injuries caused by assaults were almost the same in the two groups. Several blast injuries were identified in the first group (n = 4, 6.6%). One case each of crush, gunshot, and blast injuries were recorded, all of which were in the second group. The most common fracture location was the mandible (if considered one entity), followed by the zygoma and then the orbital floor in both groups. If the segments were considered separately, the fracture of the zygomatic bone was the most common in both groups. Zygomatic fractures accounted for 20.5% and 27.9% of the fractures in group 1 and group 2, respectively. The second most common fracture location in group 1 was the mandibular angle, while in group 2, it was the orbital floor. The third most common fracture location in groups1 and 2 was the parasymphysis. Table 1 shows the patient demographics, including sex and age, the pattern of injuries, and the types of facial fractures. Statistical analysis Statistical analysis was performed to determine the correlation between the mechanism of trauma and the type of fracture, and the results were statistically significant, with a p value 0.05). In groups 1 and 2, the mechanism of trauma was significantly correlated with the type of fracture, with a p value < 0.001. The correlation with a single fracture alone was also statistically significant, with a p value < 0.001. Discussion Two studies performed in the same region [ 8 , 15 ] examined the patterns in maxillofacial trauma in the Arabian Peninsula, Middle East, and North Africa and reported that MVAs were the most prevalent cause. Those studies described the patterns of facial fractures in the Gulf region; Jordan, although it is not in the Gulf region, is closely related to Gulf countries. There are many international relationships between Gulf countries and Jordan. With the reopening of the borders, regardless of the relations between the Gulf states and Jordan, there are relationships between tribes that require individuals to travel long distances to visit each other, which lead to mass traffic accidents. The findings of our study agree with the findings of a previous study. The rationale behind these findings is that many people work within a certain radius but have family members who live far away. The pandemic has caused a shift in the patterns of trauma; however, at the end of the pandemic, all situations returned to normal. Al Khawalde also conducted a study on the Jordanian population and reported that mandibular fractures were most commonly due to MVAs and were mostly observed in male patients. [ 16 ] Our results did not correlate with those of that study when the mandible was considered as a single entity rather than as its constituent parts. The zygomatic bone was the most common fracture site. The direct impact of the zygomatic bone on the steering wheel is usually the explanation. When the mandible is considered as a single entity a whole, mandibular fractures may be the most common. Maxillofacial trauma is not preventable even under restrictive measures, as our results revealed a high incidence of fractures caused by MVAs (32.8%). Social distancing may have influenced the cause but did not prevent fractures from occurring. There has been a change in the aetiology and mechanism of maxillofacial trauma, and we found that the pandemic caused a substantial shift in trauma management. There was a statistically significant relationship between the mechanism of trauma and the type of fracture (p 0.05). MVAs and falls are interchangeable in the Middle East. The male predominance in trauma patients has not disappeared, and many factors can explain this phenomenon. In the Middle East, owing to cultural influences and the fact that men are the primary providers in households, men are more likely to be involved in strenuous activities such as building, welding, long-distance driving (e.g., truck drivers), and many other jobs that fall into similar categories, which may contribute to the male predominance in patients who have fall-induced, blast, and crush injuries. [ 9 ] In many Western countries, falls were the predominant mechanism underlying maxillofacial trauma before and during the pandemic [ 1 , 3 , 6 , 10 – 13 ], whereas other studies reported that violence was the predominant cause. [ 4 , 14 ] The situation in Jordan was in the falls category during the pandemic, but as soon as the end of the pandemic was declared, the situation returned to normal. Assaults were not a common cause of maxillofacial trauma during or after the pandemic, with only 6 patients in group1 and 7 in group 2. MVAs were the most common cause of maxillofacial trauma in the region, regardless of the presence of pandemic-related restrictions, although there was a change during the pandemic. Almost all the studies concluded that most maxillofacial trauma patients were male. Maxillofacial surgeons in the region were socially, economically, and medically impacted by the COVID-19 pandemic. All patients had to have a negative polymerase chain reaction (PCR) result before surgery, indicating that treatment was restricted even though trauma was not. Social anxiety induced by the pandemic caused a decrease in the number of patients presenting for treatment, as stated in our study. As soon as the end of the pandemic was declared, the number of MVAs began to increase in Jordan. The pandemic also impacted patient behaviour, resulting in a population that is more likely to engage in social activities and to travel. Normal interpersonal interactions increased after the end of the pandemic, leading to an increase in the number of MVAs. We cannot fully determine the impact the pandemic had on us, but there were certainly changes. Conclusion Restrictive measures did not prevent road traffic accidents, as motor‒vehicle accidents remained common. Although facial trauma is not fully preventable, the risk can be reduced. Emphasizing the importance of safety measures at home or at work in risky situations may add to the prevention or mitigation of trauma. In coordination with hospitals and health care providers, civil defence departments and road traffic officers can promote road traffic education through local announcements, social media, educational lectures, and booths. Strict measures and actions taken against those who violate those laws and rules can also increase the awareness of the population and restrict unwanted actions and violations. Declarations Conflicts of interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Funding No funding was received to conduct this research. Ethical statement This study has been approved by the Ethical Committee of the King Hussein Medical Centre, Royal Medical Services, Hashemite Kingdom of Jordan. The research was conducted ethically in accordance with the World Medical Association Declaration of Helsinki. Author contributions The primary contributor to the conception, design, analysis of data and drafting of this manuscript was the first author, Dr. Fahad Al Qooz, including (1) the conception and design, acquisition, analysis and interpretation of the data; (2) the preparation of the draft the article and critically revision of the article with regard to important intellectual content; and (3) provision of final approval for publication of this version of the manuscript version. References Lee Dong-Woo, Choi So-Young, Kim Jin-Wook, et al. The impact of COVID-19 on the injury pattern for maxillofacial fracture in Daegu city, South Korea. Maxillofac Plast Reconstr Surg. 2021;43:35. Visholm T, Sandhu N, Dhariwal D. COVID-19: The Oral and Maxillofacial Surgery Experience, Oxford, UK. Craniomaxillofac Trauma Reconstr. 2021;14:317-324 Press S. What is the Impact of the 2020 Coronavirus Lockddown on Maxillofacial Trauma? J Oral Maxillofac Surg. 2021;79:1329. Stanisce L, Fisher AH, Choi BY, et al. How did the COVID-19 Pandemic Affect Trends in Facial Trauma? Craniomaxillofac Trauma Reconstr. 2022;15:132-138 Phillip G, Dominic S, Poorna TA, et al. Pattern of maxillofacial fractures in a Tertiary Referral Centre in Central Kerala – A comparison between the Pre-COVID and COVID periods. J Oral Biol Craniofac Res. 2022;12:45-48. Kasem A, Idan Redenski, Oren D, et al. Decline in Maxillofacial Injuries during the Pandemic: The Hidden Face of COVID-19. J Clin Med. 2022;12:128. Longino ES, Landeen KC, Wessinger BC, et al. Trends in Maxillofacial Trauma During COVID-19 at a Level 1 Trauma Center. Ear Nose Throat J. 2022:103. Ludwig DC, J. Luke Nelson, Burke A, et al. What Is the Effect of COVID-19-Related Social Distancing on Oral and Maxillofacial Trauma? J Oral Maxillofac Surg. 2021;79:1091-1097. Vishal, Om Prakash, Rohit, et al. Incidence of Maxillofacial Trauma Amid COVID-19: A Comparative Study. J Maxillofac Oral Surg. 2022;21:420-425 Salzano G, Giovanni Dell’Aversana Orabana, Audino G, et al. Have There Been any Changes in the Epidemiology and Etiology of Maxillofacial Trauma During the COVID-19 Pandemic? An Italian Multicenter Study. J Craniofac Surg. 2021;32:1445-1447 Press S. Maxillofacial Trauma and COVID-19: A Review of the First 6 Months of the Pandemic. Craniomaxillofac Trauma Reconstr. 2022;15:34-38 Puglia F and Chiu G. Comparison of oral and maxillofacial trauma during the first and third lockdown of the COVID-19 pandemic in the United Kingdom. Br J Oral Maxillofac Surg. 2022;60:465-469. Puglia F, Hills A, Dawoud B, et al. Management of oral and maxillofacial trauma during the first wave of the COVID-19 pandemic in the United Kingdom. Br J Oral Maxillofac Surg. 2021;59:867-874. de Boutray M, Kun-darbois J.-D, Sigaux N, et al. Impact of the COVID-19 lockdown on the epidemiology of maxillofacial trauma activity: a French multicentre comparative study. Int J Oral Maxillofac Surg. 2021;50:750-755. Jaber M, AlQahtani F, Bishawi K, et al. Patterns of maxillofacial injuries in the Middle East and North Africa: a systematic review. Int Dent J. 2021;71:292-299. Al-khawaldeh M. Maxillofacial fractures in Jordan: a 5-year retrospective review. Oral Surg. 2011;4:161-165 Table Table 1 is available in the Supplementary Files section Additional Declarations The authors declare no competing interests. Supplementary Files Table1Trauma.docx Table 1: Demographic and clinical data of 136 patients who underwent surgical intervention forfacial fractures during (group 1) and after (group 2) the COVID-19 pandemic. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5815066","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":402099989,"identity":"dc3b3631-5803-4a3b-ae54-e269023026c6","order_by":0,"name":"Fahad Al Qooz","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYBAC9gYeBgYgkgHzPgAxGzsBLTwHIFp4QBzGGSAtzKRoYYaQhLSwnz344Q2DHQ/f8ebDn21+bZPnY2Zg/PAxB48WnrxkyTkMyTySZ44lGOf23TZsY2Zglpy5DbcWe4YcA2keoJMMbuQYJOf23GYEamFj5sWjhYf/jfFvHoZ6sJbDlj237QlrkcgxA9pyGKTFsJnhx+1EIrS8MbOcY3Ac5Jdkxt6G28ltzIzNeP3Cw59jfONNRbUcKMQ+/Phz23Z+e/PBDx/xaIEAAyA+AMSMbSAeYwMh9VAA0sLwh0jFo2AUjIJRMKIAAE8LSjDdOxHlAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-2088-6326","institution":"King Hussein Medical Hospital","correspondingAuthor":true,"prefix":"","firstName":"Fahad","middleName":"Al","lastName":"Qooz","suffix":""},{"id":402099990,"identity":"86c29449-b389-4bb9-bcd7-c04b900d0ded","order_by":1,"name":"Mohammed S. 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Given that maxillofacial surgery is a specialty that involves close contact between surgeons and patients, many restrictions were imposed that posed challenges to surgeon. The WHO declared an end to the COVID-19 pandemic on the 11th of May 2023, and changes in patient behaviour has meant that the field of maxillofacial trauma has gradually returned to normal. Owing to restrictions put in place due to the COVID-19 pandemic and the consequent changes in human behaviour, the patterns of trauma have changed. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Visholm et al. reported that the number of patients presenting with facial trauma drastically declined during the pandemic, citing many influencing factors. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] The COVID-19 pandemic strongly impacted the population and patient behaviour. A 65% decrease in interpersonal violence during the lockdown was estimated. Social anxiety is one of the main reasons patients failed to seek care. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Stansisce et al. considered interpersonal violence to be the most prevalent cause of maxillofacial trauma, followed by MVAs. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Facial trauma is usually due to falls, MVAs, or assaults. The authors of other studies speculated that falls were the leading cause of facial trauma in the pre-COVID-19 and COVID-19 eras, followed by MVAs. [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThis study aimed to identify 1) the types of maxillofacial fractures observed during the COVID-19 pandemic and in the post-COVID-19 era; 2) the changes in the aetiology of maxillofacial trauma from the period during the COVID-19 pandemic to the post-pandemic period; and 3) the impact of lockdown restrictions on the specialty of maxillofacial surgery.\u003c/p\u003e"},{"header":"Materials \u0026 Methods","content":"\u003cp\u003eThe end of the COVID pandemic was declared on the 5th of May 2023. This retrospective study was carried out at King Hussein Medical Centre, Royal Medical Services, Hashemite Kingdom of Jordan, from May 2022 to May 2024, which included one year before and one year after the declaration that the pandemic had ended. We gathered data from our theatre logbook registry. We included data from all patients who were admitted to the maxillofacial department and underwent surgical repair of facial fractures. A total of 136 patients were included in this study.\u003c/p\u003e \u003cp\u003eThe demographic data included age, sex, mechanism of trauma, and type of facial fracture. We also subdivided the aetiology of trauma into 6 main categories: motor vehicle accidents (MVAs), falls, assaults, crush injuries, gunshots, and blast injuries. This study was conducted in accordance with the Helsinki Declaration. As a prerequisite, all patients underwent computed tomographic (CT) imaging before surgical repair.\u003c/p\u003e \u003cp\u003eThe inclusion criteria were as follows: 1) maxillofacial fracture repair; 2) any mechanism of trauma, including falls, motor-vehicle accidents, assaults, crush injuries, or gunshot injuries; 3) ages less than 75 years, regardless of sex. The exclusion criterion was the failure to fulfil any of the inclusion criteria.\u003c/p\u003e \u003cp\u003eWe separated the patients into two groups. The first group of patients included those who sustained facial fractures and underwent surgical repair during the pandemic. The second group of patients underwent surgical repair after the pandemic. The types of fractures were classified, and subgroups were analysed. Mandibular fractures were categorized into para-symphyseal, symphyseal, body, angle, and subcondylar fractures. The condyles were considered a single entity outside the mandible. All other fractures were considered single entities and included the following: zygoma (ZMC), orbital floor, naso-orbito-ethmoidal (NOE), midface, frontal, and pan-facial fractures. Pan-facial fractures included fractures involving the lower, middle, and upper face.\u003c/p\u003e \u003cp\u003eStatistical analysis was performed with IBM SPSS v29 (IBM Corp., Armonk, NY, US). Statistical significance was defined as a p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Variables were analysed with the chi-square test and Fisher\u0026rsquo;s test.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 136 patients were included in this study and were divided into two groups: those who underwent surgery during the COVID-19 pandemic (group 1) and those who underwent surgery after the COVID-19 pandemic (group 2). Their ages ranged from 2 to 72 years, with a mean of 33.38 years (SD +/- 15.21).\u003c/p\u003e \u003cp\u003eMost of the trauma patients in both groups were male. Group 1 included 61 patients, with 53 males (86.9%) and 8 females (13.1%). The ages of the male patients ranged from 8 to 74 years, with a mean of 34 years. The ages of the female patients ranged from 11 to 41 years, with a mean age of 34 years. Seventy-five patients were included in group 2, including 66 males (88%) and 9 females (12%). The ages of the male patients ranged from 11 to 70 years, with a mean age of 33.6 years. The ages of the female patients ranged from 2 to 72 years, with a mean age of 28.5 years.\u003c/p\u003e \u003cp\u003eThe most common aetiology in group 1 was falls (n\u0026thinsp;=\u0026thinsp;30, 49.2%), followed by motor‒vehicle accidents (n\u0026thinsp;=\u0026thinsp;20, 32.8%). The most common aetiology of trauma in group 2 was MVAs (n\u0026thinsp;=\u0026thinsp;50, 66.7%), followed by falls (n\u0026thinsp;=\u0026thinsp;16, 21.3%). The proportions of injuries caused by assaults were almost the same in the two groups. Several blast injuries were identified in the first group (n\u0026thinsp;=\u0026thinsp;4, 6.6%). One case each of crush, gunshot, and blast injuries were recorded, all of which were in the second group.\u003c/p\u003e \u003cp\u003eThe most common fracture location was the mandible (if considered one entity), followed by the zygoma and then the orbital floor in both groups. If the segments were considered separately, the fracture of the zygomatic bone was the most common in both groups. Zygomatic fractures accounted for 20.5% and 27.9% of the fractures in group 1 and group 2, respectively. The second most common fracture location in group 1 was the mandibular angle, while in group 2, it was the orbital floor. The third most common fracture location in groups1 and 2 was the parasymphysis. Table\u0026nbsp;1 shows the patient demographics, including sex and age, the pattern of injuries, and the types of facial fractures.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed to determine the correlation between the mechanism of trauma and the type of fracture, and the results were statistically significant, with a p value\u0026thinsp;\u0026lt;\u0026thinsp;0.001. Sex was not found to be significantly correlated in the entire sample (p value\u0026thinsp;\u0026gt;\u0026thinsp;0.05). In groups 1 and 2, the mechanism of trauma was significantly correlated with the type of fracture, with a p value\u0026thinsp;\u0026lt;\u0026thinsp;0.001. The correlation with a single fracture alone was also statistically significant, with a p value\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eTwo studies performed in the same region [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] examined the patterns in maxillofacial trauma in the Arabian Peninsula, Middle East, and North Africa and reported that MVAs were the most prevalent cause. Those studies described the patterns of facial fractures in the Gulf region; Jordan, although it is not in the Gulf region, is closely related to Gulf countries. There are many international relationships between Gulf countries and Jordan. With the reopening of the borders, regardless of the relations between the Gulf states and Jordan, there are relationships between tribes that require individuals to travel long distances to visit each other, which lead to mass traffic accidents. The findings of our study agree with the findings of a previous study. The rationale behind these findings is that many people work within a certain radius but have family members who live far away. The pandemic has caused a shift in the patterns of trauma; however, at the end of the pandemic, all situations returned to normal. Al Khawalde also conducted a study on the Jordanian population and reported that mandibular fractures were most commonly due to MVAs and were mostly observed in male patients. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] Our results did not correlate with those of that study when the mandible was considered as a single entity rather than as its constituent parts. The zygomatic bone was the most common fracture site. The direct impact of the zygomatic bone on the steering wheel is usually the explanation. When the mandible is considered as a single entity a whole, mandibular fractures may be the most common.\u003c/p\u003e \u003cp\u003eMaxillofacial trauma is not preventable even under restrictive measures, as our results revealed a high incidence of fractures caused by MVAs (32.8%). Social distancing may have influenced the cause but did not prevent fractures from occurring. There has been a change in the aetiology and mechanism of maxillofacial trauma, and we found that the pandemic caused a substantial shift in trauma management. There was a statistically significant relationship between the mechanism of trauma and the type of fracture (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Although our study showed a male predominance in both groups, the difference was not statistically significant (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). MVAs and falls are interchangeable in the Middle East. The male predominance in trauma patients has not disappeared, and many factors can explain this phenomenon. In the Middle East, owing to cultural influences and the fact that men are the primary providers in households, men are more likely to be involved in strenuous activities such as building, welding, long-distance driving (e.g., truck drivers), and many other jobs that fall into similar categories, which may contribute to the male predominance in patients who have fall-induced, blast, and crush injuries. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn many Western countries, falls were the predominant mechanism underlying maxillofacial trauma before and during the pandemic [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], whereas other studies reported that violence was the predominant cause. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] The situation in Jordan was in the falls category during the pandemic, but as soon as the end of the pandemic was declared, the situation returned to normal. Assaults were not a common cause of maxillofacial trauma during or after the pandemic, with only 6 patients in group1 and 7 in group 2. MVAs were the most common cause of maxillofacial trauma in the region, regardless of the presence of pandemic-related restrictions, although there was a change during the pandemic. Almost all the studies concluded that most maxillofacial trauma patients were male. Maxillofacial surgeons in the region were socially, economically, and medically impacted by the COVID-19 pandemic. All patients had to have a negative polymerase chain reaction (PCR) result before surgery, indicating that treatment was restricted even though trauma was not. Social anxiety induced by the pandemic caused a decrease in the number of patients presenting for treatment, as stated in our study. As soon as the end of the pandemic was declared, the number of MVAs began to increase in Jordan. The pandemic also impacted patient behaviour, resulting in a population that is more likely to engage in social activities and to travel. Normal interpersonal interactions increased after the end of the pandemic, leading to an increase in the number of MVAs. We cannot fully determine the impact the pandemic had on us, but there were certainly changes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eRestrictive measures did not prevent road traffic accidents, as motor‒vehicle accidents remained common. Although facial trauma is not fully preventable, the risk can be reduced. Emphasizing the importance of safety measures at home or at work in risky situations may add to the prevention or mitigation of trauma. In coordination with hospitals and health care providers, civil defence departments and road traffic officers can promote road traffic education through local announcements, social media, educational lectures, and booths. Strict measures and actions taken against those who violate those laws and rules can also increase the awareness of the population and restrict unwanted actions and violations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received to conduct this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has been approved by the Ethical Committee of the King Hussein Medical Centre, Royal Medical Services, Hashemite Kingdom of Jordan. The research was conducted ethically in accordance with the World Medical Association Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary contributor to the conception, design, analysis of data and drafting of this manuscript was the first author, Dr. Fahad Al Qooz, including (1) the conception and design, acquisition, analysis and interpretation of the data; (2) the preparation of the draft the article and critically revision of the article with regard to important intellectual content; and (3) provision of final approval for publication of this version of the manuscript version.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eLee Dong-Woo, Choi So-Young, Kim Jin-Wook, et al. The impact of COVID-19 on the injury pattern for maxillofacial fracture in Daegu city, South Korea. Maxillofac Plast Reconstr Surg. 2021;43:35.\u003c/li\u003e\n \u003cli\u003eVisholm T, Sandhu N, Dhariwal D. COVID-19: The Oral and Maxillofacial Surgery Experience, Oxford, UK. Craniomaxillofac Trauma Reconstr. 2021;14:317-324\u003c/li\u003e\n \u003cli\u003ePress S. What is the Impact of the 2020 Coronavirus Lockddown on Maxillofacial Trauma? J Oral Maxillofac Surg. 2021;79:1329.\u003c/li\u003e\n \u003cli\u003eStanisce L, Fisher AH, Choi BY, et al. How did the COVID-19 Pandemic Affect Trends in Facial Trauma? Craniomaxillofac Trauma Reconstr. 2022;15:132-138\u003c/li\u003e\n \u003cli\u003ePhillip G, Dominic S, Poorna TA, et al. Pattern of maxillofacial fractures in a Tertiary Referral Centre in Central Kerala \u0026ndash; A comparison between the Pre-COVID and COVID periods. J Oral Biol Craniofac Res. 2022;12:45-48.\u003c/li\u003e\n \u003cli\u003eKasem A, Idan Redenski, Oren D, et al. Decline in Maxillofacial Injuries during the Pandemic: The Hidden Face of COVID-19. J Clin Med. 2022;12:128.\u003c/li\u003e\n \u003cli\u003eLongino ES, Landeen KC, Wessinger BC, et al. Trends in Maxillofacial Trauma During COVID-19 at a Level 1 Trauma Center. Ear Nose Throat J. 2022:103.\u003c/li\u003e\n \u003cli\u003eLudwig DC, J. Luke Nelson, Burke A, et al. What Is the Effect of COVID-19-Related Social Distancing on Oral and Maxillofacial Trauma? J Oral Maxillofac Surg. 2021;79:1091-1097.\u003c/li\u003e\n \u003cli\u003eVishal, Om Prakash, Rohit, et al. Incidence of Maxillofacial Trauma Amid COVID-19: A Comparative Study. J Maxillofac Oral Surg. 2022;21:420-425\u003c/li\u003e\n \u003cli\u003eSalzano G, Giovanni Dell\u0026rsquo;Aversana Orabana, Audino G, et al. Have There Been any Changes in the Epidemiology and Etiology of Maxillofacial Trauma During the COVID-19 Pandemic? An Italian Multicenter Study. J Craniofac Surg. 2021;32:1445-1447\u003c/li\u003e\n \u003cli\u003ePress S. Maxillofacial Trauma and COVID-19: A Review of the First 6 Months of the Pandemic. Craniomaxillofac Trauma Reconstr. 2022;15:34-38\u003c/li\u003e\n \u003cli\u003ePuglia F and Chiu G. Comparison of oral and maxillofacial trauma during the first and third lockdown of the COVID-19 pandemic in the United Kingdom. Br J Oral Maxillofac Surg. 2022;60:465-469.\u003c/li\u003e\n \u003cli\u003ePuglia F, Hills A, Dawoud B, et al. Management of oral and maxillofacial trauma during the first wave of the COVID-19 pandemic in the United Kingdom. Br J Oral Maxillofac Surg. 2021;59:867-874.\u003c/li\u003e\n \u003cli\u003ede Boutray M, Kun-darbois J.-D, Sigaux N, et al. Impact of the COVID-19 lockdown on the epidemiology of maxillofacial trauma activity: a French multicentre comparative study. Int J Oral Maxillofac Surg. 2021;50:750-755.\u003c/li\u003e\n \u003cli\u003eJaber M, AlQahtani F, Bishawi K, et al. Patterns of maxillofacial injuries in the Middle East and North Africa: a systematic review. Int Dent J. 2021;71:292-299.\u003c/li\u003e\n \u003cli\u003eAl-khawaldeh M. Maxillofacial fractures in Jordan: a 5-year retrospective review. Oral Surg. 2011;4:161-165\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"facial trauma, COVID, falls, assault, motor‒vehicle accident","lastPublishedDoi":"10.21203/rs.3.rs-5815066/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5815066/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eDesign: This wasa single-centre cross-sectional retrospective study.\u003c/p\u003e\n\u003cp\u003eBackground: Facial trauma is inevitable in the field of maxillofacial surgery. Restrictive measures imposed during the pandemic increased patients’ anxiety and social awareness. Despite these changes, trauma continues through the mechanisms of falls, motor‒vehicle accidents (MVAs), alleged assaults, and other aetiologies.\u003c/p\u003e\n\u003cp\u003eObjective: To identify the changes in the patterns of maxillofacial trauma and types of fractures that occurred during and after the pandemic and the impact of the pandemic on maxillofacial trauma in the Middle East.\u003c/p\u003e\n\u003cp\u003ePatients \u0026amp; Methods: This study was conducted retrospectively at the King Hussein Medical Center, Hashemite Kingdom of Jordan, from May 2022 to May 2024. The inclusion criterion wasthe surgical repair of facial fractures during and after the COVID-19 pandemic. Patients of both sexes were included if they were under the age of 75. The exclusion criterion was the failure to fulfil the inclusion criterion. Statistical analysis was performed with IBM SPSS v29 (IBM Corp, Armonk, NY, US), with significant results indicated by a p value \u0026lt;0.05.\u003c/p\u003e\n\u003cp\u003eResults: Patients were divided into two groups: patients in group 1 underwent surgery during the pandemic, and patients in group 2 underwent surgery after it had been declared that the pandemic was over. A total of 136 patients were included in this retrospective analysis. Fall injuries were the most common mechanism of injury in group 1, although the proportion of patients who had experienced MVAs was also high, whereas in group 2, the prevalence of MVA was twice as high as in group 1. There were statistically significant differences in the mechanism of trauma and the type of fracture between both groups, both when considered together and separately (p \u0026lt;0.001). Sex was not found to be a significant factor affecting the mechanism or type of fracture (p \u0026gt; 0.05).\u003c/p\u003e\n\u003cp\u003eConclusion: Maxillofacial trauma can be controlled but cannot be prevented. An emphasis on educating the population about safety measures at home, in workplaces, and/or while driving is needed. Coordination between civil defence departments and hospitals playsan important role in educating the population and reducing the incidence and prevalence of trauma.\u003c/p\u003e","manuscriptTitle":"COVID-19 and maxillofacial trauma: are we back to where we left off?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-15 02:16:46","doi":"10.21203/rs.3.rs-5815066/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ee34f5d2-2bb8-4898-ad7f-999ad5e96fde","owner":[],"postedDate":"January 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":42858206,"name":"Dentistry"}],"tags":[],"updatedAt":"2025-01-15T02:16:46+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-15 02:16:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5815066","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5815066","identity":"rs-5815066","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}