COVID-19 Influenced the Epidemiology of Facial Trauma: A Narrative Review, 2020–2024

Abstract

The implementation of a range of social distancing and lockdown measures during the COVID-19 pandemic were seen to impact on the well-established epidemiology of facial trauma. This narrative review aimed to synthesize the international findings of this effect by evaluating the previously published literature. Relevant studies published between 1 January 2020, and 31 December 2024, were identified using four databases: PubMed, Embase, Cochrane, and SAGE Journals. A total of 63 studies across 19 countries were included. Descriptive analysis found that these were predominantly undertaken within oral and maxillofacial surgery departments (n = 48), as a single-center cohort study (n = 56), including greater than 500 patients (n = 22), with a duration of study between 1 and 52 weeks (n = 52). The principal finding was that 83% (n = 52) of studies reported a significant decrease in the number of facial trauma presentations. Falls (n = 35) in a domestic setting (n = 13) were identified, respectively, as the predominant etiology and place of injury. This is an out-of-the-ordinary observation when compared to routinely encountered causes. This study demonstrated that social distancing measures significantly influenced the epidemiology of facial trauma presentations that occurred during the pandemic.

1. Introduction

It is now just over five years since the World Health Organization’s (WHO) Director General declared that the outbreak of a highly infectious and virulent pneumonia in Wuhan City, Hubei Province, China, should be considered as a “public health emergency of international concern” [1]. In this regard, a novel coronavirus, SARS-CoV-2, was identified as being the micro-organism responsible for the development of a severe acute respiratory syndrome that was behaviorally sufficient to be characterized as a pandemic [1,2].

In view of the emergent morbidity and mortality of COVID-19, combined with the immediate lack of either an effective vaccine and/or treatment, a range of non-pharmacological public health measures were systematically employed by a number of national governments in an attempt to reduce the rate of community viral transmission [3]. These initially included the imposition of a variety of lockdown, stay-at-home, and social distancing orders, followed by the institution of contact tracing and quarantine measures. As they became available, this also involved the provision of specific diagnostic testing (rapid antigen testing and polymerase chain reaction screening) [3].

Notwithstanding intermittent episodes of “flattening of the epidemic curve” and ultimately an overall decline in the rate of community transmission (as vaccination, herd immunity, and effective anti-viral treatment supervened), the virus has continued to remain endemic and has since evolved into a number of circulating variants that are being either “monitored” or “remain of concern” to international health authorities [4,5].

Rationale and Objectives of Study

It became apparent to these authors that the implementation of a range of public health social distancing/lockdown measures to reduce COVID-19 community transmission had a serendipitous secondary effect by changing the expected frequency and characteristics of facial trauma that presented to urban tertiary referral trauma centers. Whilst there are a demonstrable number of publications in a range of specialty surgical journals that have identified this, there have been no published papers that have sought to examine the global scale of this effect [6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68].

Given the above anecdotal observations, we believed that there was merit in formally identifying this body of work and subjecting it to a comprehensive structured investigation in the form of a narrative review. The objective of this study was to determine the impact that the COVID-19 pandemic had on the epidemiology of maxillofacial trauma. Specifically, the purpose was to identify how the COVID-19 pandemic and associated public health measures of social distancing and lockdown changed the frequency and etiology of facial trauma as reported in the international literature.

2. Materials and Methods

2.1. Definitions

Facial trauma was defined as any injury involving the hard or soft tissues of the face, including fractures of facial bones, dentoalveolar trauma, and soft tissue injuries to the skin, musculature, or mucosa. Isolated ocular injuries were excluded unless coincidentally accompanied by a qualifying episode of facial trauma.

2.2. Search Strategy

A comprehensive search was conducted across four search engine databases: PubMed, Embase, SAGE Journals, and Cochrane. Searches for relevant keywords were completed on 1 January 2025. In addition, examples of known papers were obtained, and their respective bibliography/reference lists were manually scrutinized for any publications that had been omitted by the electronic search. The search terms were “facial trauma”, “COVID”, and “social distancing”; however, these terms were expanded to achieve the most thorough results:

• “Facial trauma” OR “facial injury” OR “facial fracture” OR “maxillofacial trauma” OR “maxillofacial injury”;
• “COVID” OR “COVID-19” OR “coronavirus”;
• “Social distancing” OR “lockdown”.

2.3. Study Selection

Papers were considered for review if published between 1 January 2020 and 31 December 2024. Articles were included in the study if they reported on the effect that COVID-19 pandemic social distancing laws had on altering the frequency and etiology (including a variety of accidental, non-accidental, and recidivist causes) of facial trauma.

The patient cohort could include children, adults, and the elderly, as well as any vulnerable groups therein. Relevant studies were required to be conducted in a tertiary referral (hub-spoke, regional, and supra-regional) trauma center capable of both assessing and managing the caseload. The following exclusion criteria were applied: publications that solely dealt with injuries to the eye, full text not available, articles not written in English (or, where appropriate, accompanied by a suitable English abstract), papers that did not consider multiple epidemiological factors, and articles that were not original peer-reviewed publications.

The literature search results were independently reviewed by both authors. After title and abstract screening, full article reviews and data extraction were undertaken, with any paper initially considered “indeterminant” by one and/or both authors subject to full review before inclusion/exclusion. Any discrepancies between the authors were resolved through discussion until consensus was reached.

2.4. Censorship

Censorship was set at the date of manuscript completion in preparation for submission for consideration of publication.

2.5. Data Analysis

Relevant papers were retrieved, and raw data were extracted and tabulated according to the following demographic categories: author, year of publication, country (and city) of origin, study type (single center versus multicenter), reporting specialty, duration of study, construct of study, number of patients, and synopsis of salient findings. Descriptive statistics was applied to the data and recoded as counts and percentages for categorical variables and mode, median, and mean for continuous variables.

2.6. Ethics

The authors adhered to the World Medical Association’s Declaration of Helsinki on Medical Protocol and Ethics in the conduct of this study. The study was based on a literature search and review of previously peer-reviewed and presumed hospital institutional review board-approved research protocols. No patient identifying details were disclosed.

3. Results

3.1. Literature Search

The initial database search returned 333 records in total. Figure 1 depicts the comprehensive literature search and study selection process performed by the authors. After the removal of duplicates, limiting to the English language, and selection of peer-reviewed publications only, 255 records underwent title and abstract screening. The remaining 84 studies underwent full-text screening by both authors. After applying the inclusion and exclusion criteria, a total of 63 studies were included in the review.

Of the 63 publications, the vast majority were published in either 2021 (n = 30) or 2022 (n = 22), with fewer numbers from 2020 (n = 7) and 2023 (n = 4). The studies under review were classified into having been undertaken in one of six international regions (and sub-regions), according to the United Nations Geoscheme classification (

Table 1. Incidence of publications by country of origin (as per the United Nations Geoscheme classification system).

Region	Sub-Region	Country	Number of Publications
Americas	Northern America	United States of America	11
	South America	Brazil	3
Asia	Eastern Asia	China	3
		South Korea	4
	Southern Asia	India	7
		Pakistan	1
		Sri Lanka	1
	Western Asia	Israel	1
		Turkey	3
Europe	Northern Europe	Finland	1
		Ireland	1
		United Kingdom	10
	Southern Europe	Italy	8
		Portugal	1
		Spain	1
	Western Europe	France	1
		Germany	1
		Netherlands	1
Oceania	Australia and New Zealand	Australia	3

). Articles were published across four regions and nineteen countries, most commonly from the USA (n = 11), UK (n = 10), Italy (n = 8), and India (n = 7). One additional study was collaborative and compared two sites [Australia (Newcastle) and the United Kingdom (Coventry–Warwickshire)]. There were no studies that we could find that were identified as having been undertaken in Africa or Antarctica.

The majority of included articles were published in international peer-reviewed specialty surgical journals. The participating medical disciplines that conducted the research included those from the following specialties: oral and maxillofacial surgery (n = 48), plastic and reconstructive surgery (n = 5), otolaryngology (n = 5), and emergency medicine (n = 1). The remainder were from a variety of combinations of these (n = 4).

Fifty-six studies were undertaken in a single center, while six were undertaken on a multicenter basis involving recruitment from either four, five, six, nine, thirteen, or twenty-nine sites. One study was comparative (involving two single sites). All studies were undertaken in a tertiary referral center that was capable of both comprehensively assessing and definitively managing patients who presented with facial trauma.

The studies were conducted over a variable time span. The majority (n = 52) (for ease, Group I) were conducted between one and fifty-two weeks. The mode of this group was eight weeks, the median was eleven weeks, and the mean was sixteen weeks. The remaining studies (n = 11) (for ease, Group II) were all conducted for greater than one year, (range: 8 months to 12.5 years). The mode and median of this group was two years, and the mean was just under four years.

Of the Group I studies, twenty-three compared 2020 figures with 2019 figures (for the same time period), seven compared 2020 with 2019 and 2018 figures (again for the same time period), and four others compared 2020 with additional pre-COVID years. Thirty-eight studies used a variety of dates between February and March 2020 as the commencement date, consistent with the date of mandatory lockdown in their respective countries.

The patient numbers that were recruited into the studies varied according to the influence that COVID-19 had on their respective epidemiology. However, as a best summative assessment, n = 6 studies considered less than 100 patients, n = 13 studies considered patient numbers between 100 and 200, n = 22 studies considered patient numbers between 200 and 500, and n = 22 studies considered patient numbers greater than 500.

3.2. Incidence of Facial Trauma

Overwhelmingly, 83% (n = 52) of the identified studies revealed a decrease in the number of facial trauma presentations during the COVID-19 period, with a mean decrease in incidence of 39% (range: 2–96% decrease). Figure 2 depicts the percentage change in the incidence of maxillofacial trauma during COVID restrictions (lockdown, social distancing), as compared to the pre-COVID cohort, excluding outliers. Only six studies showed an increase in incidence, whilst the remaining five either showed no change or were not reported.

Five studies additionally compared the incidence of facial trauma to the equivalent period following the repeal of their respective nations’ COVID restrictions. Predominately, the studies reported on the early phase of the pandemic in 2020 (n = 3) and 2021 (n = 1). However, one study analyzed data from 2023, following the World Health Organization’s de-escalation of COVID-19 from pandemic status. All studies reported an increase in frequency following the repeal of restrictions, with a return to either a comparable (n = 1) or a statistically significant increase (n = 4) in frequency as compared to the pre-pandemic cohorts (Figure 3).

3.3. Etiology of Facial Trauma

The etiology of maxillofacial trauma during the COVID-19 and control groups was extracted (as available) from the included publications. Appendix A,

Table A1. Etiology of facial trauma in the COVID cohort and the change in this incidence as compared to the control cohort.

First Author, Year of Publication	Incidence (as % Change from Control to COVID Cohort)	Etiology of Facial Trauma (as % of COVID Cohort)								Change in Etiology Incidence (as % Change Between Control and COVID Cohort)
		Falls	RTA	IPV	Sport	DA	DV	SH	Animal	Falls	RTA	IPV	Sport	DA	DV	SH	Animal
Araujo, 2022 [6]	4% decrease	47%	24%	21%	3%					−4%	−1%	6%	1%		23%
Barca, 2020 [7]	-													↑
Blackhall, 2020 [8]	Decrease	62%		8%			7%	1%		↑	↓	↓			↑
Bohneberger, 2021 [9]	24% decrease	19%	34%	12%	13%					3%	6%	−3%	1%
Boom, 2022 [10]	51% decrease	21%	58%	21%	0%					6%	Nil	Nil	−3%
Canzi, 2020 [11]	17% increase		24%	9%	7%	20%	20%	17%			−20%	4%	Nil	12%		11%
Chundoo, 2023 [12]	25% decrease	94%	2%						4%	1%	2%						−2%
Clark, 2021 [13]	68% decrease	43%	12%	33%	6%		3%					−16%
Dawoud, 2021 [14]	Nil change	30%	10%	45%	2%					5%	5%	−17%	−3%
De Boutray, 2021 [15]	65% decrease	20%		40%	5%	11%		6%
Donohoe, 2021 [16]	47% decrease
Famà, 2021 [17]	56% decrease
Ferragina, 2022 [18]	20% decrease	54%	23%	23%				2%		↑	↓	↑			18%
Figueiredo, 2022 [19]	52% decrease	30%	15%	20%						3%	−15%	−6%	−67%
Gabriele, 2022 [20]	41% decrease
Gangwani, 2021 [21]	39% increase	30%	19%	23%	3%		1%	5%	2%	−1%	−2%	2%	−4%		1%	1%
Giovannetti, 2022 [22]	159% increase	37%	17%	30%	14%					27%	−32%	22%	−15%
Gourishetti, 2023 [23]	8% decrease
Guo et al., 2020 [24]	-	>50%								↑
Haapanen, 2021 [25]	No change	56%	4%	14%						14%	−1%	−18%
Hoffman, 2021 (UK) [26]	73% decrease	54%	3%	22%	0%				5%	24%	−2%	−23%	−9%				−1%
Hoffman, 2023 (AU) [27]	30% decrease	38%	8%	26%	14%		4%		6%	17%	−3%	−12%	−4%		4%		Nil
Infante-Cossio, 2022 [28]	35% decrease	34%	34%	27%	5%					−3%	12%	8%	2%
Irgebay, 2022 [29]	57% decrease		41%	3%	15%	13%				31%		−11%	−15%	−4%
Ismail, 2021 [30]	76% decrease	39%	29%	5%	1%				2%	11%	13%	7%	3%				1%
Kadanthode, 2022 [31]	32% decrease									↑		↑
Kanna, 2020 [32]	107% decrease	9%	79%	8%	0%				1%		−16%	7%	−1%				1%
Kasem, 2022 [33]	80% decrease	40%	10%	30%	0%					Nil	Nil	Nil	Nil
Kim, 2021 [34]	22% decrease	15%	13%	24%	7%	31%				−24%	4%		−4%	27%
Kim, 2022 [35]	25% decrease	43%	26%	15%	4%					7%	−4%	−3%	−5%
Koca, 2021 [36]	74% decrease	25%	13%	34%	5%	20%				−12%	1%	17%	−8%	1%
Lee, 2021 [37]	23% decrease	46%	26%	16%	1%	4%				2%	−1%	Nil	−3%	−1%
Lee, 2023 [38]	57% decrease														50%
Lentge, 2021 [39]	14% increase		5%	12%	26%						1%	5%	2%
Longino, 2022 [40]	37% increase
Ludwig, 2021 [41]	27% decrease	29%	31%	21%						−9%	−3%	6%
Marchant, 2021 [42]	4% decrease			9%			1%					Nil			Nil
McEwen, 2021 [43]	73% decrease (UK)	54%	3%	22%	0%	5%				24%	−2%	−23%	−9%				−1%
	30% decrease (AU)	38%	8%	26%	14%		4%		6%	17%	−3%	−12%	−4%		4%		Nil
Meera, 2022 [44]	44% decrease	50%	30%	20%						10%	−12%	2%
Nawaz, 2022 [45]	-	19%	66%	8%
Neiva-Sous, 2022 [46]	32% decrease	41%	18%	23%	0%					15%	4%	−16%	−10%
Nhongo, 2022 [47]	28% decrease	44%	3%	32%	4%		7%			18%	2%	−12%	−13%		6%
Ozkan, 2021 [48]	43% decrease	56%	14%	19%	2%				1%	13%	Nil	−7%	1%				Nil
Philip, 2022 [49]	46% decrease	18%	67%	8%	3%					8%	2%	−4%	−1%
Press, 2021 [50]	36% decrease	34%	26%	21%	18%					5%	2%	−18%	9%
Press, 2022 [51]	25% decrease	31%	31%	25%	13%					5%	6%	−15%	4%
Puglia, 2021 [52]	-	39%		23%	19%		6%
Puglia, 2021 [53]	53% decrease	42%		24%	13%		4%			4%		1%	−7%		−2%
Qiu, 2021 [54]	19% decrease	38%	8%	26%	14%		4%		6%	17%	−3%	−12%	−4%		4%		Nil
Salzano, 2020 [55]	69% decrease	51%	23%	14%	1%			0%		16%	Nil	−9%	−16%
Shenoi, 2022 [56]	53% decrease	32%	47%	16%						9%	−26%	13%
Spallaccia, 2022 [57]	48% decrease	27%	36%	13%	13%					↑	Nil	↓	↓
Stanisce, 2021 [58]	28% decrease		38%	34%			10%		6%		19%	−1%			6%		1%
Suleiman, 2022 [59]	82% decrease
Surendra, 2021 [60]	900% increase	68%	13%	6%	2%					16%	↓	↑
Tipirneni, 2021 [61]	27% decrease	34%	9%	48%	2%		5%			Nil	−3%	8%	−8%		−3%
Vishal, 2022 [62]	77% decrease	11%	61%	25%						1%	−24%	21%
Visholm, 2021 [63]	33% decrease
Wang, 2020 [64]	30% decrease	38%	8%	26%	14%				6%	17%	−3%	−12%	−4%		4%		Nil
Yang, 2021 [65]	72% decrease	89%	8%		0%					39%	−29%		↓
Yeung, 2021 [66]	64% decrease	53%	11%	24%			1%	3%	0%	6%	2%	1%			−4%	3%	−3%
Yoon, 2021 [67]	32% decrease	27%	5%	5%	3%		1%			−8%	2%	Nil			1%
Zhang, 2021 [68]	44% decrease	71%

Abbreviation Key: ↑—increase (where numerical data not reported); ↓—decrease (where numerical data not reported).

summarizes this data by publication, further comparing how the incidence of these factors was altered between the control and COVID cohorts (i.e., increased, decreased, or no change). For ease of interpretation, the identified injury precipitants were then tabulated for comparison (

Table 2. Summary of salient features, including changes in etiology in the COVID period versus control groups.

	No. of Papers That Reported on This Outcome	Number of Papers That List as Leading Cause of Trauma Within COVID Cohort (%)	Average Incidence Within COVID Cohort (Range %)	Number of Papers Where Incidence Increased Between Control and COVID Cohort	Average Increase in Incidence (Range %)	Number of Papers Where Incidence Decreased Between Control and COVID Cohort	Average Decrease in Incidence (Range %)	Number of Papers with no Change Between Control and COVID Cohort
Injury Precipitant
Falls	46	35 (66%)	40% (9–94%)	33	11% (1–39%)	7	9% (1–24%)	2
RTA	46	10 (19%)	24% (1–79%)	15	6% (1–38%)	22	11% (1–32%)	5
IPV	48	5 (9%)	21% (3–48%)	16	8% (1–22%)	23	11% (1–23%)	5
DV	17	0	4% (1–10%)	12	12% (1–50%)	3	3% (2–4%)	1
Sport	37	1 (2%)	7% (0–26%)	6	3% (1–9%)	24	9% (1–67%)	2
DA	8	2 (4%)	17% (3–37%)	5	17% (1–27%)	2	3% (1–4%)	0
Animal	11	0	4% (0–6%)	3	<1% (1%)	3	2% (1–3%)	5
Self-harm	7	0	5% (0–17%)	3	5% (1–11%)	0	-	0
Other
DS	14	-	-	13	19% (7–52%)	1	-	0
D & A use	13	-	-	6	9% (3–14%)	5	16% (5–39%)	2

Abbreviation Key: RTA—road traffic accident; IPV—interpersonal violence; DV—domestic violence; DA—domestic accident; DS—domestic setting; D & A—drug and alcohol.

).

The most common cause of facial trauma during the COVID-19 period was ascribed to falls (66%), followed by road traffic accidents (RTA) (19%), interpersonal violence (IPV) (9%), domestic accidents (DA) (4%), and sports (2%). The incidence of each precipitant was quite variable across the papers, although it still showed a similar trend to the leading causes. Falls had the highest incidence, attributing to on average 40% of injuries (range 9–94%) within the cohorts. This was followed by RTA at 24% (range 1–79%), IPV at 21% (range 3–48%), and DA at 17% (range 3–37%). Other less common causes during the COVID-19 period included sports, self-harm, animals, and domestic violence.

There were significant changes in etiology incidence between the control and COVID-19 groups. Of the publications that reported on the incidence of falls, 72% showed an increased incidence by an average of 11% (range 1–39%). In addition, 71% of studies with data on domestic violence showed an increased incidence by an average of 12% (range 1–50%). Although there was an increase in DV, more than half of the publications showed a decrease in the number of presentations due to IPV by an average of 11% (range 1–23%). RTA and sports were also more likely to show a decrease in incidence by an average of 11% (range 1–32%) and 9% (range 1–67%), respectively.

Fourteen studies reported on the location where injuries were sustained, with 93% finding an increase in the number of injuries occurring in the domestic setting, with an average increase of 19% (ranging from 7 to 54%). Of the 13 studies that addressed alcohol and/or drug use, 46% (n = 6) showed an increase in concomitant substance use during COVID-19. On average, this increase in incidence was by 9%, ranging from 3 to 14%. Of note, whilst fewer studies (n = 5) showed a decrease in alcohol and/or drug use, the decrease in incidence was on average by a greater amount of 16%.

4. Discussion

It has generally been accepted that the COVID-19 pandemic has had and continues to have both a profound direct and indirect impact on individuals, communities, and governments. To reduce the Ro (effective rate of infection) of community transmission of the SARS-Cov-2 virus, many national governments simultaneously imposed a range of stringent “social distancing” and mandatory quarantine laws on their respective populations [3]. Almost with an immediate effect, an unintended secondary consequence of these laws was a change to the frequency and characteristics of the well-recognized epidemiology of trauma presentations to tertiary referral hospitals [69]. This also included the facially injured cohort of patients [6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68].

History will dictate that a cluster of cases of severe pneumonia caused by a novel coronavirus was first detected in provincial China in December 2019 [1]. International authorities confirmed that the epicenter of the outbreak was the city of Wuhan, in Hubei Province. The disease quickly established itself and then spread both within and subsequently, due to the effect of “globalization”, beyond China’s borders [1,4]. Not surprisingly, our study revealed that the first report on the impact that lockdown policies had on the presentation of facial trauma emanated from China [24]. In all, three Chinese studies wrote of their respective experiences from 23 January 2020–20 February 2020, 23 January 2020–7 April 2020, and 24 January 2020–23 March 2020; notably, these were before the WHO declaration of the pandemic on 11 March 2020 [10,24,66].

Guo et al. were the first to publish a small study that identified that falls had started to emerge as the primary etiology of facial trauma [24]. Yang et al. subsequently identified a 71.8% reduction in the number of presentations and similarly confirmed that falls comprised 89% of the injured cohort [65]. Zhang et al. identified reductions of 36.85% and 43.7% in presentations (compared to 2018/2019 figures), with 62.2% of injuries occurring indoors and 70.8% of injuries being the result of a fall [68]. These observations were subsequently replicated by almost every publication that we investigated in our analysis.

In keeping with the WHO confirmation of COVID-19 as a pandemic, our review identified a total of sixty-three studies derived from nineteen different countries, reflecting four international regions and nine sub-regions. A total of six papers were published in the first year of the pandemic (2020); this included China (n = 1), Italy (n = 2), the United Kingdom (n = 1), Australia (n = 1), and Sri Lanka (n = 1) [7,8,11,24,60,64]. As the virus spread beyond China, so did the country of origin of the publications. We identified the emergence of studies from Italy (n = 8), the west coast of the United States of America (n = 2), and South Korea (n = 4), in keeping with the start of the first wave of the pandemic [7,11,17,18,20,22,34,35,37,41,42,55,57,67].

An early collaborative comparative study (Australia–United Kingdom) in 2021 upheld the contemporaneous anecdotal observations of the lead clinicians that the frequency and characteristics of facial trauma were changing, with a reduction of 30% identified in the Australia cohort and a reduction of 73% identified in the United Kingdom cohort, conducted (in comparable units over an 8-week comparable lockdown period) in 2020 [26].

Arguably, the principal finding of our literature review was that 83% (n = 52) of the studies that were reviewed revealed a significant decrease in the number of facial trauma presentations to tertiary referral centers. The mean reduction was 39%, ranging from 2% to 95%. Falls (n = 35 studies) in the home (n = 13 studies) were identified as the predominant cause and place of injury.

A notable secondary finding was that the widespread imposition of lockdown laws was seemingly responsible for altering the etiological causes of maxillofacial trauma presentation. Historically, the global leading causes of facial trauma can be attributed to road traffic accidents and interpersonal violence, which is supported by Pereira et al.’s recent systematic review [70]. Significantly, our research identified alterations to this amongst the COVID cohorts when subjected to various restrictions, which resulted in an increase in falls as the leading cause with a concomitant reduction in road traffic accidents and interpersonal violence.

The reduction in road traffic accidents could reasonably be accounted for by the imposition of the various lockdown laws limiting non-essential travel, public transport, and the overall number of vehicles and pedestrians on roads. The global transition to “work from home” policies further contributed to reducing traffic congestion. Similarly, the decrease in levels of interpersonal violence was likely a combination of an inability to engage in large social gatherings and either restrictions or shutdown of pubs, bars, and clubs, the venues that are well known to be responsible for occurrences of alcohol-fueled violence.

Alternatively, the increase in high-level falls (from trestles, ladders, and scaffolds), was likely due to a behavioral shift, with people undertaking a number of “do-it-yourself” home tasks. In addition, the increase in low-level falls was perhaps a reflection of an increase in electronic sales and contact-free home delivery of alcohol. Household slips and trips were also umbrellaed by this category. There was potentially a reluctance for the elderly to visit their general practitioner due to the significant risk of contracting COVID-19. This may have in turn led to an increase in falls due to neglected medical management coupled with a proportion of accidental mechanic falls that are common occurrences in this age group.

Another interesting finding was the inverse relationship between a decreasing incidence of interpersonal violence and an increasing incidence of domestic violence. Twelve publications reported an increase in the incidence of domestic violence by an average of 12% (ranging from 1 to 50%) [6,8,11,18,21,26,37,43,47,54,58,64,67].

On reflection, the pandemic likely precipitated an increase in domestic violence due to a combination of forced proximity with social distancing/lockdown measures, overall higher rates of alcohol consumption facilitated by new home delivery services, and increased financial and emotional stressors. Restrictions on movements and travel likely further perpetuated this effect, making it increasingly difficult to extricate oneself from the volatile situation.

The continued ramifications of coronavirus spread, without regard for national boundaries, established that the number of studies submitted and accepted for peer-reviewed publication progressively rose from seven in the first year of the pandemic to thirty in 2021. As the pandemic plateaued, publications in 2022 reduced a little to twenty-two and at the time of submission sat at four in 2023. We were also able to ascertain the surgical specialties that conducted the investigations and were responsible for publication. Perhaps not surprisingly, oral and maxillofacial surgery (n = 48) was the primary discipline that was responsible for the assessment and management of facial trauma in most countries.

Strengthening the overall link between the imposition of “stay at home”/“lockdown” laws and the reduction in injury presentation, five studies identified that following the relaxation of lockdown laws, there was almost an immediate increase in trauma presentations that returned to expected levels [8,10,50,54,56]. Interestingly, there were a few studies that differed from these global observations. Gangwani et al. noted a 39.2% increase in facial trauma presentations and no significant change in etiology in their study that took place in Rochester, New York State, between 20 March 2020 and 24 June 2020 (compared to a similar period in 2019) [21]. They surmised that this result was likely due to an increase in alcohol consumption as a reflection of “social isolation, financial hardship from loss of employment, and anxiety due to an uncertain future”. This was upheld by identifying an increase in the number of study patients who presented with positive alcohol levels.

In a 2020 Sri Lankan study, Surendra et al. compared maxillofacial trauma presentations in a 3-month COVID-19 “lockdown” period (1 March 2020–31 May 2020) with a 26-month pre-COVID “control” period (17 November–20 January) [60]. Their investigation revealed 208 patients (averaging 70 per month) during lockdown and 174 patients (averaging 7 per month) during the control period. This equated to a tenfold increase in trauma presentation during COVID. In keeping with the overall literature findings, the study upheld that fall (as a cause of injury) increased (as a proportion from 51.7% pre-COVID to 68.2% COVID) and that up to 82.4% of trauma incidents took place in the home (COVID) compared to 17.6% (pre-COVID).

Two studies failed to reveal any statistical evidence of change in the presentation of facial trauma. This contrasts with fifty-two studies that identified a decrease and six studies that identified an increase. Arguably the archetypal study that showed no impact of COVID-19 on the presentation of facial trauma is a Finnish study by Haapanen et al. in the spring of 2020 [25]. The first COVID-19 case reported in Finland was confirmed on 29 January 2020, when a Chinese tourist from Wuhan tested positive for the coronavirus. Unfortunately, the authors were unable to proffer any reason as to why their study showed no difference in the number of facial trauma presentations when comparing COVID-19 with a pre-COVID control.

The importance of these observations is that changing human behavior and activity can result in considerable alterations to the frequency and etiology of maxillofacial trauma. The future applicability of these findings is then considering how public health measures can be tailored to reproduce favorable epidemiological changes, especially in the event of another microbiological pandemic and/or public health emergency. However, approaching this on a global scale may pose several challenges in terms of accessing, managing, and analyzing the high volume of patient data.

As evidenced in our findings, there was only a very limited number of papers performed as multicenter, with only one that compared international sites. Our recommendation would be for surgical units to consider engaging in international research collaboratives, which have produced high levels of research, such as The POSTVenTT Study and REALITI-A Study [71,72].

Participation in such groups may pose a challenge in terms of obtaining relevant institutional ethics committee approval, with concerns over maintaining patient confidentiality in the handling and storage of data. Dar et al. proposed an interesting method that could circumvent this issue with the use of a blockchain framework that allows for the decentralization, anonymity, and enhanced security of COVID-19 data [73]. Secondarily, this may also be sufficient to allow the data to be analyzed using machine learning algorithms to predict health outcomes, such as what was performed by Iwendi et al., and thus assist in directing public health policy and clinical management [74].

5. Conclusions

5.1. Strengths and Weaknesses

The major strength of this study was that trauma presentation and etiology data were constant across the respective publication regions and countries. In addition to the references and abstracts that were captured by our accessing the relevant biomedical search engines, we broadened our search by manually cross-checking individual publication reference lists. The selected publications were all observational and contemporaneous and were all influenced by the one global event (COVID-19 pandemic). The weakness of this study is that potentially some publications were excluded by inbuilt errors of omission or commission and perhaps inbuilt risk of bias in recruitment (e.g., restricting our study to those papers in the English language).

5.2. Conclusions

Facial trauma is a relatively common injury with a variable etiology and a worldwide incidence. This review is the first article that comprehensively analyzes the impact of the COVID-19 pandemic on the etiology of facial trauma. Our review of the literature upholds the premise that the social engineering imposed by national governments, primarily to curb the community spread of coronavirus, also uniquely served as an effective secondary public health measure to reduce the number of, as well as influence the etiology of, facial trauma presentations to tertiary referral hospitals.

As a corollary, it can be seen that public health measures are capable of promoting population behavioral changes, which can reduce the incidence of facial trauma. Knowledge of the described epidemiological changes is necessary to direct future resource allocation in the event of another microbiological pandemic and/or public health emergency.