Victor Paes Dias Gonçalves*

victor.diaes.paes@gmail.com

lucas.berard@usp.br

Bruno Gomes**

bruno.gomes@usp.br

Carlos Maurício Fontes Vieira*

vieira@uenf.br

Felipe Perissé Duarte Lopes*

felipeperisse@gmail.com

Henry Alonso Colorado Lopera***

henry.colorado@udea.edu.co

Neide Pena Coto**

npcoto@usp.br

*Advanced Materials Laboratory

State University of the North of Rio de Janeiro Darcy Ribeiro (UENF) (Brazil)

**Department of Maxillofacial Surgery, Prosthetics and Traumatology

School of Dentistry - University of São Paulo (USP) (Brazil)

***CCComposites, Engineering school

Universidad de Antioquia (UdeA) (Colombia)

Reception: 06/03/2024 - Acceptance: 09/24/2024

1st Review: 08/26/2024 - 2nd Review: 09/21/2024

Accessible document. Law N° 26.653. WCAG 2.0

Suggested reference: Gonçalves, VPD, Berard, LT, Gomes, B., Fontes Vieira, CM, Lopes, FPD, Colorado Lopera, HA, & Coto, N.P. (2024). Retrospective video analysis of orofacial injuries during FIFA World Cup Qatar 2022 Lecturas: Educación Física y Deportes, 29(317), 89-102. https://doi.org/10.46642/efd.v29i317.7702

 

Abstract

    Introduction: Football Association is the most practiced sport in the world. However, as a contact sport in which athletes are subject to impacts and injuries of different etiologies, the risk of orofacial injuries is high. Objective: The aim of the present study was to investigate the incidence of orofacial injuries during the FIFA World Cup - Qatar 2022™. Materials and Methods: Video analyses were performed of all 64 games of the World Cup, with the determination of the quantity of orofacial injuries that occurred between players as well as the different types and characteristics of these injuries. The data were incorporated into a database and subsequently analyzed with the aid of the SPSS program (version 17.0). Results: At least one orofacial injury occurred in 96.87% of the games. The greatest incidence of orofacial injury was due to impacts. Four athletes used a face shield and only one used a mouthguard. Conclusion: The incidence of orofacial injuries was high among the players who participated in the 2022 World Cup and impact was the most frequent etiology of such injuries.

    Keywords: Athletes. Sports. Soccer. Facial trauma.

 

Resumo

    Introdução: O futebol é o esporte mais praticado no mundo. No entanto, como um esporte de contato em que os atletas estão sujeitos a impactos e lesões de diferentes etiologias, o risco de lesões orofaciais é elevado. Objetivo: O objetivo do presente estudo foi investigar a incidência de lesões orofaciais durante a Copa do Mundo FIFA - Catar 2022™. Materiais e métodos: Foram realizadas análises videográficas de todos os 64 jogos da Copa do Mundo, determinando a quantidade de lesões orofaciais ocorridas entre os jogadores, bem como os diferentes tipos e características dessas lesões. Os dados foram incorporados a um banco de dados e posteriormente analisados com o auxílio do programa SPSS (versão 17.0). Resultados: Pelo menos uma lesão orofacial ocorreu em 96,87% dos jogos. A maior incidência de lesões orofaciais foi devido a impactos. Quatro atletas usaram protetores faciais e apenas um utilizou um protetor bucal. Conclusão: A incidência de lesões orofaciais foi alta entre os jogadores que participaram da Copa do Mundo de 2022 e o impacto foi a etiologia mais frequente dessas lesões.

    Unitermos: Atletas. Esportes. Futebol. Trauma facial.

 

Resumen

    Introducción: El fútbol es el deporte más practicado en el mundo. Sin embargo, al ser un deporte de contacto en el que los deportistas están sujetos a impactos y lesiones de diferentes etiologías, el riesgo de lesiones orofaciales es alto. Objetivo: El objetivo del presente estudio fue investigar la incidencia de lesiones orofaciales durante la Copa Mundial de la FIFA - Qatar 2022™. Materiales y métodos: Se realizaron análisis de video de los 64 partidos de la Copa Mundial, con la determinación de la cantidad de lesiones orofaciales ocurridas entre jugadores, así como los diferentes tipos y características de estas lesiones. Los datos se incorporaron a una base de datos y posteriormente se analizaron con la ayuda del programa SPSS (versión 17.0). Resultados: Al menos una lesión orofacial ocurrió en el 96,87% de los partidos. La mayor incidencia de lesión orofacial se debió a impactos. Cuatro atletas usaron protector facial y solo uno usó protector bucal. Conclusión: La incidencia de lesiones orofaciales fue alta entre los jugadores que participaron en el Mundial 2022 y el impacto fue la etiología más frecuente de dichas lesiones.

    Palabras clave: Deportistas. Deportes. Fútbol. Traumatismo facial.

 

Lecturas: Educación Física y Deportes, Vol. 29, Núm. 317, Oct. (2024)

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Introduction 

 

    Football Association is the most widely practiced and popular sport worldwide, demanding high performance from athletes (Cometti, Na, & Maffulli, 2001; Raja, Venkatachalam, & Qoronfleh, 2021). During the 2018 FIFA World Cup in Russia, a report indicated that nearly 40% of the global population understands the sport well and supports it (Raja, Venkatachalam, & Qoronfleh, 2021).

 

    With the increase in competitiveness and widespread participation in the sport, there has been a rise in orofacial injuries related to football (Persic, Pohl, & Filippi, 2006; Andrade et al., 2010). As a contact sport, football players are susceptible to injuries, trauma, and concussions (Coto, Meira, & Dias, 2010; Farrington et al., 2012). This issue has garnered attention from researchers investigating the occurrence of such injuries. According to Correa et al. (2012) and Kinalski et al. (2020), most injuries to professional football players occur in the head region.

 

    The incidence of oral traumas has also significantly increased, as reported in the literature (Andrade et al., 2010; Verissimo et al., 2016). The use of mouthguards is not universal among athletes, and their incidence is not high (Coto et al., 2017; Gialain et al., 2016). Mouthguards made with ethylene vinyl acetate (EVA) are highly recommended to prevent these injuries. (Verissimo et al., 2016)

 

    Therefore, the aim of the present study was to investigate the incidence of orofacial injuries during games of the FIFA World Cup - Qatar 2022™.

 

Methods 

 

    An exploratory, descriptive study with a quantitative approach was conducted to determine the incidence of injuries during all 64 games of the 2022 World Cup. The games were analyzed through videos made available on the internet by the organizers of the event. Injuries were analyzed in accordance with the ethical principles stipulated in the Declaration of Helsinki, using audiovisual material in the public domain (Harriss, & Atkinson, 2015). According to the American Psychological Association (2002), an observational study in a natural environment with public videos obtained through means of mass communication does not imply experimentation and does not require the informed consent of the competitors. Two reviewers investigated the variables of interest independently. Divergences of opinion were resolved by discussion with a third researcher until a consensus was reached.

 

    The analysis was based on the study conducted by Correa et al. (2012). The following aspects were considered: type of injury (bleeding, impact, laceration, fracture, and concussion; in cases of multiple injuries, the most severe was considered), region of the head/face affected, causal agent (ball, post, arm, head, elbow, hand, shoulder, lower extremity), period (first half, second half, extra time), referee’s action (no foul, foul, yellow card, red card), player’s position (goalkeeper, fullback, wingback, midfielder, and attacker), zone of field (defense, midfield, attack), and severity (mild, when the player remained lying on the ground for at least 15 seconds after being struck or seemed to be in pain but did not receive medical care; moderate, when the player needed to leave the field to be treated; severe, when the player needed to be substituted). The quantity of substitutions, reason for the injury, and use of a face shield and mouthguard were also determined.

 

    The assessment of low and moderate severity has a bias, as players on a winning team may simulate injuries to waste time. Therefore, to define the severity assessment, the evaluators reviewed the incident three times to confirm the impact and verify that there was no simulation. As this competition received widespread media coverage, serious diagnoses were supported by consulting the federation's official website or news from major media sites in cases where they could not be identified by video analysis.

 

Results 

 

    Sixty-four games were analyzed: 48 in the group phase and 16 in the knockout phase of the competition. Four games in the knockout phase went into extra time. The total time among all games was 5880 minutes.

 

Orofacial injuries 

 

    At least one orofacial injury occurred in 96.87% of the games: 3.03% had no injuries; 27.27% had one; 19.7% had two; 25.76% had three; 7.58% had four; 7.58% had five; 3.03% had six; 4.55% had seven; and 1.52% had eight incidents. There was a total of 181 incidents (an average of 2.8 incidents per game), with an average rate of occurrence of one incident every 32.4 minutes. In Table 2, the distribution of 119 impacts to the head region and 62 to the face can be observed.

 

    Despite the high frequency of impacts without substantial repercussions, 4% of the events required the substitution of players. Moreover, players needed to leave the game, even if only for a few moments, to receive off-field care in 7% of the incidents. The head was the most affected area, and such injuries occurred mainly when leaping to dispute the ball.

 

    As most games did not have extra time, this period was not analyzed statistically. However, more injuries occurred in the second half, possibly due to greater fatigue during this period. Tables 1-8 provide a structured overview of the orofacial injuries, their frequencies, and related details in the given dataset.

 

Type of Injury	Frequency (Percentage)
Impact	169 (93%)
Concussion	6 (3%)
Laceration	4 (2%)
Bleeding	1 (1%)
Fracture	1 (1%)

Source: Research data

 

Region	Frequency (Percentage)
Head	119 (66%)
Face	62 (34%)

Source: Research data

 

Period	Frequency (Percentage)
1st half	81 (45%)
2nd half	96 (53%)
Extra time	4 (2%)

Source: Research data

 

Causal Agent	Frequency (Percentage)
Hand	34 (19%)
Elbow	33 (18%)
Head	31 (17%)
Shoulder	31 (17%)
Arm	16 (9%)
Ball	13 (7%)
Lower extremity	14 (8%)
Post	1 (1%)

Source: Research data

 

Severity	Frequency (Percentage)
Mild	154 (85%)
Moderate	24 (13%)
Severe	3 (2%)

Source: Research data

 

Position	Frequency (Percentage)
Midfielder	62 (34%)
Attacker	49 (27%)
Wingback	32 (18%)
Fullback	28 (15%)
Goalkeeper	10 (6%)

Source: Research data

 

Decision	Frequency (Percentage)
No foul	88 (49%)
Foul	82 (45%)
Yellow card	19 (10%)
Red card	1 (1%)

Source: Research data

 

Zone	Frequency (Percentage)
Defense	73 (40%)
Midfield	59 (33%)
Attack	49 (27%)

Source: Research data

 

Substitutions 

 

    A total of 588 substitutions occurred during the competition (431 in the group phase and 157 in the eliminatory phase). Fifty-one substitutions (8.65%) were due to injuries (39 in the group phase and 12 in the eliminatory phase); one was due to an orofacial injury and two were due to concussions, with an average of one substitution due to injury every 115 minutes. Information on injuries was obtained from the TransferMarket platform, which is a valid sports databank that provides information on injuries. This platform has been used as a data source for studies on football association.

 

Use of mouthguard and face shield 

 

    Four different players used a face shield and participated in 17 games (26.56% of all games). Three of these players were from European countries and one was from an Asian country. Only one player used a mouthguard. This player was from an Asian country and participated in four games (4.69%).

 

Country	Protection Used	Number of matches with Protection
Japan	Mouthguard	4
Tunisia	Face Shield Sports	3
South Korea	Face Shield Sports	4
Croatia	Face Shield Sports	7
Belgium	Face Shield Sports	3

Source: Research data

 

Discussion 

 

    The present study followed the method described by Correa et al. (2012), who analyzed videos of games from the Brazilian tournament. The authors analyzed 113 games and found an incidence of orofacial injuries of 84.1%, with an average of 2.0 incidents per game. The present study consisted of the analysis of 64 games, 96.87% of which had at least one orofacial injury, with an average of 2.8 incidents per game.

 

    The predominance of impacts in the head region (66%) aligns with data reported by Serner et al. (2022), who observed 88 impacts to the head during the FIFA Arab Cup 2021™, with an average of two impacts to the head per game, 44 of which (50%) resulted in a medical assessment on the field. The average of two impacts to the head per game reinforces the need for greater use of protocols and the presence of a dental surgeon to provide immediate care to the teams. These findings are consistent with an article published by Kinalski et al. (2020), who evaluated craniofacial injuries in football players during three official FIFA competitions. A high number of craniofacial incidents were observed in recent FIFA competitions. Head-to-head impacts, lacerations, and fractures were associated with greater incident severity.

 

    Analyzing the type of orofacial injury, impact by a strike was the most common, which aligns with the predominant form of injury described by Correa et al. (2012). However, it should be noted that the severity of such injuries cannot always be considered mild. Indeed, 13% of the injuries in the present study were moderate and 2% were severe, requiring the substitution of players. These data demonstrate the importance of having dentists perform emergency treatment as quickly as possible for lacerations to the face, bleeding, and fractures, and to apply concussion protocols. A total of 8.65% of the substitutions during the games were due to injuries, with one substitution due to injury occurring every 115 minutes.

 

    The 2022 World Cup was the first competition to test an additional substitution rule if a player suffered a concussion to preserve the health of the athletes and improve the protocol for substitutions due to concussion. In the video analysis, three severe injuries occurred that required substitution: two concussions and one fracture. In the two cases of concussion, an extra substitution was added, but not at the time of the occurrence. Both times, the players returned to the field, which is not recommended in the protocol. Indeed, Tarzi et al. (2022) concluded that football medical staff rarely follow protocol.

 

    According to the protocol, unlike contusions, concussions cause temporary brain dysfunction; the athlete must be immediately substituted and remain under medical observation for at least 12 hours. Padilha et al. (2021) state that a mouthguard assists in the prevention of concussion by increasing the space between the head of the condyle and glenoid fossa as well as providing greater stabilization of the head by activating and strengthening the neck muscles.

 

    Mouthguards and face shields are intraoral and extraoral devices, respectively. A mouthguard has important functions related to the prevention of tooth fractures and injuries, avoiding lacerations of the lip, tongue, and soft tissues, and preventing abrupt contact between the mandible and maxilla (Coto et al., 2012; Gialain et al., 2016). A face shield should be used to prevent facial trauma during sports and, in cases of impact, prevents the fractured bone from further fracturing or displacement (Tarzi et al., 2022). Face shields can also be considered a device for the prevention of orofacial fractures that can lead to athletes suspending their sports activities until the complete regeneration of the fractured bone tissue. (Cascone et al., 2008; Tarzi et al., 2022)

 

    The video analysis enabled the determination of the use of mouthguards and face shields. A mouthguard was used by only one athlete throughout the entire competition. Several injury prevention efforts have been introduced in the sport, including protective equipment, rule changes, and national injury prevention programs. Besides protection, authors (Collares et al., 2014; Martins et al., 2020) point out that a mouthguard does not negatively impact sports performance and that educational actions with athletes are needed. To be successful, the presence of dentists is needed in football clubs to improve the behavior of the players and expand the multidisciplinary nature of the health team. (Gonçalves et al., 2021; Queiroz et al., 2013)

 

    The use of a face shield was seen among four athletes in 26.56% of the games. This type of protective equipment is used when an athlete suffers a fracture to the bones of the face and keeps the athlete from being left out of games. Sports dentistry manufactures this device so that athletes can resume training immediately, enabling a faster return to the game. These numbers underscore the important role of dentists in the fast return of athletes who suffer fractures in other competitions, enabling them to participate in the main football competition in the world.

 

    Pioneering studies have been carried out using mouthguards to detect head accelerations and record kinematic data in various sports. A pioneering study by Kercher et al. (2022) conducted a multi-site prospective study in one season with players from three high school football teams, with 74 athletes. Each player wore a mouthguard with a sensor, which monitored the frequency of head impacts. After controlling for duration, increases in head impact outcomes were observed by the level of contact. This information supports the relationship between chronic head impact exposure and declining brain health.

 

    One limitation of the study is that the severity of craniofacial injuries was assessed depending on the time the player remained lying on the ground, whether they received medical care, or the need to leave the field. However, it is very common for players on a winning team to want to waste time when they receive a foul. The evaluators reviewed the incident three times to confirm the impact and that there was no simulation. In future research, it may be interesting to assess whether the team was winning or losing.

 

    Although it is not possible to access medical information or other external data collections, studies with video analysis are becoming increasingly innovative (Correa et al., 2012; Kinalski et al., 2020; Serner et al., 2022; Rance, 2022) and allow for reliable data due to the quantity and quality of cameras in TV broadcasts and replays with zoom that can remove doubts about the incident and display the exact location of the impact, increasingly contributing to scientific research.

 

    Current literature has been increasingly focused on investigating the use of 3D printing for manufacturing custom mouthguards, aiming to enhance their application in sports competitions (Li et al., 2020; Szarek, & Paszta, 2020; Unkovskiy et al., 2021; Sousa, Pinho, & Piedade, 2021; Pinho, & Piedade, 2022; Saunders et al., 2022; Schewe et al., 2022; Moreira et al., 2021; Trzaskowski et al., 2023). This advanced method offers greater precision and user adaptation, providing optimized comfort and protection (Gonçalves et al., 2024). This refined approach could signify a qualitative leap in athletic performance, making mouthguards more suitable and effective for elite athletes.

 

Conclusion 

 

    The incidence of orofacial injuries among athletes who participated in the FIFA World Cup - Qatar 2022™ was high. The types of orofacial injuries that occurred included impacts, concussions, bleeding, and fractures, with a predominance of impacts.

 

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Lecturas: Educación Física y Deportes, Vol. 29, Núm. 317, Oct. (2024)