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 Table of Contents  
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 88-95

Effect of law enforcement system (Saher) on maxillofacial injuries caused by road traffic accidents in Riyadh

1 Department Of Oral & Maxillofacial Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
2 Riyadh Elm Universty, Riyadh, Saudi Arabia

Date of Web Publication19-Aug-2019

Correspondence Address:
Dr. Raed S Almanea
Riyadh Elm Universty, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjos.SJOralSci_3_18

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Background: Road traffic accident (RTA) is one of the major causes of facial injuries apart from other body injuries.
Aims and Objectives: The aim of this study was to assess the effectiveness of law enforcement system (LES) on maxillofacial injuries caused by RTAs in Riyadh.
Materials and Methods: The objective was achieved by conducting a comparison of RTA - related facial injuries before and after the introduction of Saher. A retrospective study on patients admitted to Prince Sultan Medical City Oral and maxillofacial surgery department of 10 years divided equally before and after the introduction of the LES. Data were collected from the hospital's electronic database regarding the patients' age, sex, gender, date, time, and type of injury.
Results: The severity and the number of injuries from RTAs were considerably reduced with the introduction of the system.
Conclusion: LES plays a huge role toward controlling how road users use the roads and consequently, the number of accidents reported.

Keywords: Law enforcement system, maxillofacial injuries, road traffic accident

How to cite this article:
Alasseri N, Almanea RS, Algarni MS, Alajmi SS, Jeleudan WS, Alsaeed MI. Effect of law enforcement system (Saher) on maxillofacial injuries caused by road traffic accidents in Riyadh. Saudi J Oral Sci 2019;6:88-95

How to cite this URL:
Alasseri N, Almanea RS, Algarni MS, Alajmi SS, Jeleudan WS, Alsaeed MI. Effect of law enforcement system (Saher) on maxillofacial injuries caused by road traffic accidents in Riyadh. Saudi J Oral Sci [serial online] 2019 [cited 2020 Mar 30];6:88-95. Available from: http://www.saudijos.org/text.asp?2019/6/2/88/264761

  Introduction Top

Road traffic accident (RTA) is one of the most difficult subjects around the world. According to the World Health Organization, more than 3000 people are killed daily on the road and 30,000 others injured or disabled.[1] Kiran et al.[2] postulate that the situation is made worse by factors such as increasing population and vehicular density with meager infrastructure in place to support them. Batstone et al.[3] indicate that RTAs can be linked to a number of factors such as the road conditions, the local road regulations, vehicle type, and the attitude of the driver. Driver fatigue and the use of alcoholic drinks are other factors which have been blamed for RTAs. According to Bartsone, RTA incidences in the developed countries is much lower compared to that of the developed countries as attributed to the lack of proper regulations and much older cars. Facial injuries in the Middle Eastern countries are predominantly due to RTA.[4] In Saudi Arabia, one of the largest countries in the Middle East traffic police reported that every 40 min a person dies and 68,000 other injured every year due to RTA. In response to this affliction in April 4, 2010, the interior ministry of the Kingdom of Saudi Arabia implemented the law enforcement system (LES), which is a network of cameras and fixed and mobile radars to monitor, control traffic violations automatically, and issue violation notices (RTA and LES).

In Saudi Arabia, a motor vehicle is employed as the primary means of transportation for its populace. According to Ansari et al.,[5] up to 564 762 people were injured as a result of RTA in the country between 1971 and 1997. The injured in this case translated to 3.5% of Saudi Arabia's population. The statistics from the same period also pointed out to the fact that four people were injured and one killed on an hourly basis in the country. Wani et al. (2012)[6] highlighted the fact that in spite of the much improvements to address the challenges related to peripheral vascular injuries, the condition is still a major contributor to mortality and morbidity. From Wani's perspective, the gravity of vascular injuries is attributed to the fact that without urgent interventions death or the loss of certain body parts can easily occur.

The maxillofacial area is very sensitive area since it is the most exposed and prone to injury in an RTA, another reason making the maxillofacial area unique is the complexity that this area obtained which make maxillofacial injury very difficult to treat and manage.[7] However, there is considerably less amount of data on the maxillofacial injuries, due to RTA after the implantation of LES.

Several countries around the world implemented the LES before Saudi Arabia. For instance, in 2006 Kuwait implanted Penalty Points System (PPS) in response to the increasing number of road traffic injuries (RTIs) and to eliminate reckless driving behaviors which ultimately result in considerably less number of RTIs mortality and morbidity. Therefore, implantation of the PPS could be a splendid way to reduce RTIs.[8] For this reason, this study aims to test the hypothesis that there is a reduction in the number and severity of the maxillofacial injuries in Prince Sultan Military Medical City Riyadh since the introduction of LES.

  Materials and Methods Top

This retrospective study was carried out on the patients admitted to Prince Sultan Medical City Oral and Maxillofacial Surgery (OMFS) Department. The targeted patients were divided equally into 10–5 years before and after the introduction of ELS. Data were collected from the electronic database of the patients admitted to the OMFS Department of PSMC. Data targeted covered areas such as sex, age, date, nationality, time type of injury, and any other data which would have been helpful toward the conclusion of the study. The data collected was then analyzed using the SPSS (Version 21, IBM Corp., Armonk, NY, USA) statistical package for social sciences computer program.


The selected sample entailed patients whose clinical records and radiographs indicated that they had RTA-related facial injuries and had been referred to Prince Sultan Military Medical City between April 2005 and April 2014.

Data collection

Data collected included age, nationality, gender, and dates which were divided between before and after the implementation of the ELS system. In regards to the injuries, they were categorized in relation to their location on the face, for instance, upper, middle (including zygoma and condyle) lower (including maxilla and mandible). More than one associated injuries were further grouped according to the relevant specialties into neurosurgery, cardiothoracic, orthopedic, and general and multiple surgeries and FISS.

  Results and Statistical Analysis Top

The facial injury severity score (FISS) was grouped into mild (FISS 1–3), moderate (FISS 4–7), and severe injuries (FISS 8–15). The statistical analysis involved descriptive statistics of age, gender, nationality, year; FISS data, location, and other injuries. All the collected data were statistically analyzed using statistical software (IBM SPSS Statistics Version 20). For all statistical purposes, a P ≤ 0.05 was considered statistically significant.

Up to 168 patients met the criteria put in place for the research. The males comprised 87.5% while the females comprised 12.5% [Figure 1] and [Table 1]. In regards to nationality, most of those affected were predominantly Saudi at 98.8% [Figure 2]. The injury prevalence before the introduction of Saher was higher at 58.9% as compared to 41.1% reported after [Figure 3].
Figure 1: Gender-wise distribution of study subjects

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Table 1: Characteristics of the study subjects

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Figure 2: Nationality of the study subjects

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Figure 3: Before and after Sahar

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It was observed that no patient sustained upper face instances were however reported for the lower and middle locations. The FISS mean for lower and middle locations was observed to be 1.38 and 2.54, respectively. Those who had multiple face location injury, on the other hand, had a FISS mean of 4.18 (while their SD was 0.57, 1.13, and 2.97 for the lower middle and multiple face locations in that order) [Figure 4].
Figure 4: Distribution of fracture locations

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The various injuries which were observed are highlighted in [Figure 5]. Out of the total injuries seen in 168 patients, facial surgery at 87.5% emerged as the most predominant injury under the category of those requiring various disciplines for treatment with 147 patients being treated for the condition. Those injuries requiring orthopedic surgery came in distant second with 4.2% followed closely by those requiring neurosurgery, multiple surgeries, and general surgery at 4.2%, 3%, and 1.2%, respectively.
Figure 5: Injuries requiring various disciplines for treatment

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In relation to the FISS, those with mild injuries contributed the largest fraction of the patients at 69.6% (117). The second runners up were those with mild injuries at 17.9% (30) of the cohort. The least category was those with severe conditions at 12.5% (21) of the entire population [Figure 6].
Figure 6: Distribution of subjects based on facial injury severity score severity

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Regarding the age of the patients, their average was 27.66 years with the minimum being 4.00 years. The maximum age, on the other hand, was 64 years. The standard deviation (SD) of 11.52 years implies that the ages of the targeted population were spread out from the mean [Figure 7].
Figure 7: Age of subjects (in years)

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Most of the patients suffered minimal injuries as a result of RTA as compared to those who suffered maximum severity as a result of the injuries. As indicated in [Figure 8], the mean FISS was 3.32, SD 2.60, while the minimum and maximum FISS was 1.00 and 13.00, respectively.
Figure 8: Facial injury severity score

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In comparison to the females, the men had a lower FISS mean at 3.16 as compared to that of the females at 4.43 [Table 2]. Further men's SD was at 2.48 which was lower than that of the females at 3.14. In essence, it implies that the female's FISS had a higher dispersion from the mean when compared to that of the men.
Table 2: Mean and standard deviation of facial injury severity scores among different groups

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In terms of nationality, the Saudi had a higher FISS mean (3.34) which is double that of the aliens (1.5). In addition, it was observed that their SDs varied vastly with that of the Saudi are 2.6 and that of other nationalities at 0.71.

A comparison of incidences before and after the introduction of Saher revealed a close relationship between the two periods. A FISS mean of 3.16 was recorded for patients admitted before the introduction of the system while a mean of 3.54 was recorded after. For the same periods, a SD of 2.35 and 2.91 has been registered before and after Saher introduction, respectively.

The mean of the FISS for those who had facial injuries only was reported at 3.33 and SD of 2.56. The mean of the FISS for those who required orthopedic surgery was observed to be 2.86 with an SD of 2.12. The highest mean, however, was reported in the incidences pertaining to those who required neurosurgery (mean = 3.71, SD = 3.82). The FISS mean for those requiring general surgery and multiple surgeries was 2.00 and 3.6, respectively. Their SDs, on the other hand, ranged 0–3.58 in that order for general and multiple surgeries.

A comparison of the FISS between the different locations of the face before and after Saher system produced distinct results. The results for the incidences before the installation of the system produced a P < 0.001 for the middle*Lower, P < 0.001 for middle*more than one and P = 0.006 for lower*more than one. On the other hand, the P value after the installation of the system was calculated at 0.006 for middle*lower, P = 0.001 for middle*more than one and (P = 0.08) for lower*more than one [Table 3].
Table 3: Comparison of facial injury severity score between different locations before and after Saher system

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The results of a comparison of FISS between other injuries before and after the installation of the Saher system are in sharp contrast. For instance, the number of those who experienced facial injuries dropped from 88 to 59 after the introduction of the system [Table 4]. The other surgeries remained fairly the same with orthopedic surgery dropping from 4 to 3 and neurosurgery rising from 3 to 4. General surgery remained constant while multiple surgeries dropped from 3 to 2 instances. The Chi-square was calculated at 2.43 before and 4.005 after the implementation of Saher (ELS). Conversely, the P value before was 0.656 and 0.405 after installation of the Saher both of which are marginal. The relationship between the different variables, in this case, is deemed as being insignificant as attributed to the P value which is greater than the cutoff which is 0.005.
Table 4: Comparison of facial injury severity score between other injuries before and after Saher system

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  Discussion Top

Saudi Arabia is one of the fastest developing countries in the world. This implies that most resources which are required to manage the mushrooming populations in the cities have not been addressed adequately. The installation of the LES is one major step taken by the country toward the control of the spiraling RTAs. The research has pointed out that human behavior is to be blamed for the increasing RTA incidences; hence, the need to put in place punitive measures to curb the trend was timely. On the other hand, studies have pointed out that human factors may not be entirely blamed for the rising RTAs. Apparently environmental factors may contribute toward the reduction in visibility and condition of the roads.

In the recent study, the minimum age of the victims was 27.66 years. This finding is similar to what was reported earlier by others.[2] Apparently, this age is associated with personal independence, intense mobility, and social excitements which predispose one to careless driving and utilization of the roads. The same age group has been associated with urban violence.[9] The research also points out to the fact that there were no incidences reported for individuals below 4 years and above 64 years.[2] The phenomenon has been attributed to the fact that the older individuals (64 years and above) are less mobile. Singh et al.[10] attribute the lower accident incidences in, the older cohorts to high experience as far as the handling of the cars and traffic is concerned. On the other hand, those below 4-year-old probably are taken care of by the elders apart from also being less mobile. The fact that individuals from the active age group are affected by the RTA is an unfortunate trend. Apparently, according to Singh et al.,[10] this condition results in not only lost revenue regarding reduced man hours but also increased expenditure in terms of medication for the affected individuals. The finding is not in line with that of Gissane and Bull, whose observation revealed that individuals aged 60 years and above were prone to RTA as compared to the other age groups.

The males were 87.5% more likely to be involved in the accidents as compared to the women. This trend is similar to that highlighted in various previous researches on RTA. Apparently, the statistics can be attributed to the fact that the male is the more empowered sex in the society and would in more instances be the owners of the vehicles as compared to the women. A similar study conducted by Wood and Freer [11] revealed that the males were more likely to be involved in RTA as attributed to the fact that they were the most common users of vehicles. Agnihotri et al.[12] corroborated the above findings in their study which was carried out in India. The previous research indicated that men were 78% more likely to be involved in fatal accidents as compared to females. This phenomenon was attributed to the fact that the males in Indian society were bored the burden of generating earning for their families.

Another finding from the study also indicated that the Saudi was the most likely victims as compared to individuals from other nationalities (Saudis = 166, others = 2). This figure goes in line with the findings of research conducted by Al-Khateeb and Abdullah [13] in the UAE. The research had highlighted the fact that most of the victims of RTAs were UAE nationals. Both studies are a reflection of the predominant nationalities within the targeted regions. In Saudi Arabia, for instance, the Saudi nationalities make up the largest proportion of the population, and hence it would be naturally expected that they would feature predominantly on the list of the most affected.

The accident incidences also dropped from 58.9% to 41.4% after the introduction of the system. This result is in tandem with various researches which has indicated that the stricter regulations served to reduce RTA incidences. Agnihotri et al.[12] pointed out to the fact that human factor was to be attributed to up to 64%–71% of RTA. Andersson [14] observed that countries in Europe and North America have managed to bring down RTA incidences down from 25% to 30% witnessed four decades ago to a low of 3%–8%. A comparison of FISSS before and after the introduction of the system was done, as depicted in [Figure 3] also highlight the gravity of the situation. The P values for the different incidences indicate that the results are quite significant. For instance, a P < 0.001 before and a P = 0.002 after the introduction of the system. In addition, the FISS severity score comparison pointed out to the fact that there was a significant reduction in the severity of the injuries. Apparently, before the introduction of the system, the occurrence of the severity level of injuries was much higher when compared to those which occurred latterly [Table 5].
Table 5: Comparison of facial injury severity score severity before and after Saher system

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These findings are a clear pointer of the effectiveness of the system put in place. From the observation, stricter laws put in place managed to cut down RTA incidences in spite of the fact that the number of cars had increased considerably over the same period. Ansari et al.(2000, p. 37) postulated that the high accident rates which were reported in Saudi Arabia were due to the lack of adherence to the set traffic rules and over speeding. The previous study had pointed out that up to 65% of all the RTA accidents reported were as disobeying traffic signals. The reduction indicated by the study can, therefore, be attributed to increased adherence to the traffic signals and reduced speeds.

On the contrary, in regards to the study comparing the type of injury inflicted before and after system introduction revealed an insignificant change. This finding can be attributed to the fact that the factors which contributed to the existence of types of surgeries (facial surgery, orthopedic surgery, neurosurgery, general surgery, and multiple surgeries) were not eliminated or changed by the system put in place. Wood and Freer [11] highlight the fact that RTA-related incidences are still high in spite of the strict legislations and systems put in place to regulate road use. The use of safety belts, for instance, has played a huge role in reducing the impact sustained by passengers in case of impacts. Resultantly, minor injuries such as abrasions were reported due to the head contact with steering wheels. In this case, the severity of the injury could be attributed to the type of material used in the manufacture of the car parts such as the steering wheel. According to Wood and Freer,[11] the use of softer materials which can deform on contact can go a long way toward the elimination of facial injuries. Essentially from the study, it is evident that other measure apart from legislations has to be put in place.

The study also indicated that the patients comprised predominantly of those who sustained more than one facial injury (100 out of 168). The above-highlighted finding is similar to the revelation from previous studies which had indicated that multiple facial injuries were prevalent among the victims of RTAs. Mid and lower face accounted for 26 (15.5%) and 42 (26%) incidences, respectively. These findings contrast that of Srinivasan [9] which revealed a mid and lower face injury prevalence at 42.85% and 28%, respectively. It also contrasts that of Gray 8 which the author had reported at 62.7% and 10.5% for the mid and lower face injuries, respectively. Both the previous injuries indicate that the mid-face injuries were higher than those reported in the lower face locations.

From the study, injuries requiring facial surgery were the most common with 147 out of the 168 (translating to 87.5%) being admitted to the hospital for the medical condition. Those requiring orthopedic and neurosurgery were both reported at 4.2% while those requiring multiple surgeries were 3% of the population. These findings contrasted to that carried out by Batstone et al.,[3] which revealed that up to 50% orthopedic injuries resulting from the use of motorcycles as the mode of transport. The fact that the face is the most exposed part is one of the factors which contribute to the high incidences of injuries. According to Weihsin et al.,[7] the maxillofacial area is not only exposed but also difficult to treat as attributed to its complicated structure. A study conducted by Malara et al.[15] corroborated the above assertions by revealing that most RTA injuries involve the soft tissues followed mandibular fractures and tooth-related injuries.

The distribution based on FISS or the injuries revealed that most of the incidences involved mild injuries at 69.6%. Moderate injuries followed at 17.9% while severe injuries contributed 12.5%. These findings were in contrast to a previous research by Kiran et al.[2] which had indicated mild injuries at 58.4%, moderate injuries at 30.4%, and severe injuries at 11.2%. The previous research was also conducted based on the trauma index score, unlike the FISS used in this study.

  Recommendation and Conclusion Top

The results point out to the fact that in spite of the introduction of the system, RTA incidences are still predominant. However, there is a clear indication that the trend is on the downward trend wit reported cases reducing. As indicated from the study, the most affected groups are the individuals who fall under the youth category. The authorities should, therefore, ensure that this group of people is properly educated on the importance of observing road rules and regulations. In order to implement these measures, the local authorities should organize seminars under which education on first aid techniques will be imparted on the populace. Stricter rules should also be put in place as evidenced by the fact that those inputs in place are already bearing fruits. It will, therefore, be important to ensure that the said rules are streamlined to encompass all areas of transport which may have been left out by the system in place.

Besides education and training of road users, the stakeholders should also look into other factors such as environmental and the design of cars and other vehicles. Proper designing of vehicles will ensure that the road users are protected in case of RTA occurrence hence reducing the occurrence of facial injuries. As indicated above, the use of appropriate safety belts and well-designed steering wheel can go a long way toward alleviating some of the most severe injuries.

Further, it is evident from the various researches that a complete elimination of RTA cases is not easy as attributed to many factors such as human error and environmental factors. Therefore, in order to address the plight of the patients, the development of rapid response facilities can go a long way toward minimizing the severity of injuries. A proper diagnosis and treatment will in this regard help mitigate conditions which could have been life-threatening.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Hussain OT, Nayyar MS, Brady FA, Beirne JC, Stassen LF. Speeding and maxillofacial injuries: Impact of the introduction of penalty points for speeding offences. Br J Oral Maxillofac Surg 2006;44:15-9.  Back to cited text no. 1
Kiran ER, Saralaya KM, Vijaya K. Prospective study on road traffic accidents. J Punjab Acad Forensic Med Toxicol [serial online] 2004;4:12-6.  Back to cited text no. 2
Batstone MD, Monsour FN, Pattel P, Lynham A. The patterns of facial injury suffered by patients in road traffic accidents: A case controlled study. Int J Surg 2007;5:250-4.  Back to cited text no. 3
Rabi AG, Khateery SM. Maxillofacial trauma in al madina region of Saudi Arabia: A 5-year retrospective study. Asian J Oral Maxillofac Surg 2002;14:10-4.  Back to cited text no. 4
Ansari S, Akhdar F, Mandoorah M, Moutaery K. Causes and effects of road traffic accidents in Saudi Arabia. Public Health 2000;114:37-9.  Back to cited text no. 5
Wani ML, Ahangar AG, Wani SN, Dar AM, Ganie FA, Singh S, et al. Peripheral vascular injuries due to blunt trauma (road traffic accident): Management and outcome. Int J Surg 2012;10:560-2.  Back to cited text no. 6
Weihsin H, Thadani S, Agrawal M, Tailor S, Sood R, Langalia A, et al. Causes and incidence of maxillofacial injuries in India: 12-year retrospective study of 4437 patients in a tertiary hospital in Gujarat. Br J Oral Maxillofac Surg 2014;52:693-6.  Back to cited text no. 7
Akhtar S, Ziyab AH. Impact of the penalty points system on severe road traffic injuries in Kuwait. Traffic Inj Prev 2013;14:743-8.  Back to cited text no. 8
Srinivasan P. Road traffic accidents under the influence alcohol causing maxillofacial trauma: One year retrospective study. Indian J Multidiscip Dent 2014;4:911.  Back to cited text no. 9
  [Full text]  
Singh R, Bghatnager M, Singh HK, Singh G, Kumar Y,et al. An epidemiological study of victims of road traffic accidents cases: A study from national capital region (Ghaziabad), India. Indian J Prev Soc Med 2011;42:28-33.  Back to cited text no. 10
Wood EB and Freer TJ. Incidence and aetiology of facial injuries resulting from motor vehicle accidents in Queensland for a three-year period. Aust Dent J 2001;46:284-8.  Back to cited text no. 11
Agnihotri A, Galfat D, Agnihotri D. Incidence and pattern of maxillofacial trauma due to road traffic accidents: A prospective study. J Maxillofac Oral Surg 2014;13:184-8.  Back to cited text no. 12
Al-Khateeb T, Abdullah FM. Craniomaxillofacial injuries in the United Arab Emirates: A retrospective study. J Oral Maxillofac Surg 2007;65:1094-101.  Back to cited text no. 13
Andersson L. Road traffic accidents – A cause of death and trauma. Dent Traumatol 2011;27:1.  Back to cited text no. 14
Malara P, Malara B, Drugacz J. Characteristics of maxillofacial injuries resulting from road traffic accidents – a 5 year review of the case records from department of maxillofacial surgery in Katowice, Poland. Head Face Med 2006;2:27.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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