Audrey Yoon, DDS

All Publications

• Craniofacial anatomical determinants of pediatric sleep-disordered breathing: A comprehensive review. Journal of prosthodontics : official journal of the American College of Prosthodontists Kim, K. A., Kim, S. J., Yoon, A. 2024

  Abstract

  This narrative review aims to elucidate the anatomical features of sleep-disordered breathing (SDB) in children. By identifying key structures and intervening proactively, we seek to alter craniofacial growth patterns and improve functional outcomes for SDB children.The literature on pediatric sleep-disordered breathing (PSDB), pediatric obstructive sleep apnea (OSA), anatomical predispositions, and the relationship between skeletal deformity and PSDB was examined using PubMed and Google Scholar databases, covering studies from 2006 to 2024.Forty relevant articles were reviewed, focusing on craniofacial characteristics associated with PSDB. The etiology of PSDB is multifactorial, with adenoid and palatal tonsil enlargement being the most common cause. While adenotonsillectomy is recommended as the primary treatment, residual SDB may result in craniofacial skeletal deformities contributing to upper airway constriction. Typical craniofacial phenotypes of SDB include excessive vertical growth and constriction of the maxilla, a retruded mandible, and posterior rotation, known as a Class II hyperdivergent pattern. Conversely, Class III with an underdeveloped maxilla shows a relatively lower risk for SDB due to reduced nasal cavity and nasopharyngeal airway volumes. Transverse maxillary constriction with a high, deep palatal vault is a significant risk factor. Additionally, nasal obstruction and low tongue posture, with or without a short lingual frenulum, are identified as craniofacial risk factors for SDB development in children.Early diagnosis and intervention are critical in managing PSDB. Dentists, through screening and early treatment, can significantly influence craniofacial growth and health outcomes. A multidisciplinary approach is essential for effective management, improving the quality of life and long-term health of affected children.

  View details for DOI 10.1111/jopr.13984

  View details for PubMedID 39557815

• A Roadmap of Craniofacial Growth Modification for Children with Sleep Disordered Breathing: A Multidisciplinary Proposal. Sleep Yoon, A., Gozal, D., Kushida, C., Pelayo, R., Liu, S., Faldu, J., Hong, C. 2023

  Abstract

  Craniofacial modification by orthodontic techniques is increasingly incorporated in the multidisciplinary management of sleep disordered breathing in children and adolescents. With increasing application of orthodontics to this clinical population it is important for healthcare providers, families, and patients to understand the wide range of available treatments. Orthodontists can guide craniofacial growth depending on age; therefore, it is important to work with other providers for a team-based approach to sleep-disordered breathing. From infancy to adulthood the dentition and craniofacial complex change with growth patterns that can be intercepted and targeted at critical timepoints. This article proposes a clinical guideline for application of multi-disciplinary care with emphasis on dentofacial interventions that target variable growth patterns. We also highlight how these guidelines serve as a roadmap for the key questions that will influence future research directions. Ultimately the appropriate application of these orthodontic techniques will not only provide an important therapeutic option for children and adolescents with symptomatic sleep disordered breathing but may help also mitigate or prevent its onset.

  View details for DOI 10.1093/sleep/zsad095

  View details for PubMedID 37014012

• What changes in maxillary morphology from distraction osteogenesis maxillary expansion (DOME) correlate with subjective and objective OSA measures? Sleep & breathing = Schlaf & Atmung Yoon, A., Kim, T. K., Abdelwahab, M., Nguyen, M., Suh, H. Y., Park, J., Oh, H., Pirelli, P., Liu, S. Y. 2023

  Abstract

  To correlate skeletal and airway measures on imaging with polysomnographic and self-reported measures after distraction osteogenesis maxillary expansion (DOME), in the effort to identify clinically relevant sites of expansion to guide treatment for adult patients with obstructive sleep apnea (OSA).This is a retrospective study reviewing subjects who underwent DOME and had the complete set of the following data: peri-treatment cone-beam computed tomography (CBCT) scans, polysomnography (PSG), Epworth Sleepiness Scale (ESS), and nasal obstruction symptom (NOSE) scores.Of 132 subjects who underwent DOME, 35 met inclusion criteria (71% men, mean age 27.7 ± 6.5 years, mean BMI 26.0 ± 6.4 kg/m2) and were enrolled in the study. There was a significant reduction in the NOSE score from 11.4 ± 5.5 to 3.6 ± 3.1, in the ESS score from 12.0 ± 4.6 to 7.1 ± 4.7, and in the apnea-hypopnea index (AHI) from 17.1 ± 15.8 to 7.01 ± 6.2 (p < 0.0001), after DOME. Nasal floor width at the nasopalatine canal level showed a statistically significant correlation with AHI reduction (p < .0001).DOME is significantly associated with reduction of nasal obstruction, sleepiness, and severity of OSA. The findings suggest that expansion at the anterior third of the bony nasal passage, specifically where the nasopalatine canal is located predicts its clinical efficacy. This site may be a useful target anatomically via imaging.

  View details for DOI 10.1007/s11325-022-02761-5

  View details for PubMedID 36806968

  View details for PubMedCentralID 3826282

• Impact of rapid palatal expansion on the size of adenoids and tonsils in children. Sleep medicine Yoon, A., Abdelwahab, M., Bockow, R., Vakili, A., Lovell, K., Chang, I., Ganguly, R., Liu, S. Y., Kushida, C., Hong, C. 2022; 92: 96-102

  Abstract

  Adenoid and tonsillar hypertrophy in children often leads to adverse respiratory symptoms and obstructive sleep apnea (OSA). Current clinical guidelines from the American Academy of Pediatrics and American Academy of Otolaryngology-Head and Neck Surgery recommend tonsillectomy as the first line of pediatric OSA treatment for children with tonsillar hypertrophy. Rapid palatal expansion (RPE) performed by orthodontists improves obstructive sleep apnea in children by reducing nasal airway resistance, increasing nasal volume, raising tongue posture, and enlarging pharyngeal airway. However, the role of RPE in alleviating adenoid and tonsillar hypertrophy remains elusive. In this study, we aim to evaluate the changes in adenoid and palatine tonsil sizes following RPE using 3D volumetric analysis of cone beam computational tomography (CBCT) imaging.In this retrospective cohort study, a total of 60 pediatric patients (mean age: 8.00, range: 5-15, 32 females and 28 males) who had tonsillar hypertrophy (size 3 and 4) were included and divided into the control group (n = 20) and expansion group (n = 40). The control group did not undergo any treatment. The expansion group underwent RPE using a conventional Hyrax expander, activated 0.25 mm per day for 4-6 weeks. Final CBCT scans (T2) were performed 13.8 ± 6.5 months after the initial scan (T1). Pediatric sleep questionnaire (PSQ) and BMI were obtained at each timepoint. Volumetric analysis of adenoid and palatine tonsils was performed using a combination of bony and soft tissue landmarks in CBCT scans through Anatomage Invivo 6 imaging software. Paired t-tests were used to evaluate the difference between the initial and final adenoid and tonsil volumes. p values less than 0.05 were considered statistically significant.Compared to the control group, the expansion group experienced a statistically significant decrease in both adenoid and tonsil volume. There was non-statistically significant increase in volume from T1 to T2 for the control group. For the expansion group, 90.0% and 97.5% of patients experienced significant reduction in adenoid and tonsil volume, respectively. The average volume decrease of adenoids was 16.8% while that of tonsils was 38.5%. The patients had up to 51.6% and 75.4% reduction in adenoid and tonsil size, respectively, following RPE orthodontic treatment. Pearson correlation ranged from 0.88 to 0.99 for each measurement, representing excellent internal consistency. There was a significant reduction in the PSQ scores from 5.81 ± 3.31 to 3.75 ± 2.38 in expansion group (p < 0.001).Our results demonstrated that RPE significantly reduced the size of both adenoid and palatine tonsils and revealed another long-term benefit of RPE treatment. To our knowledge, this is the first study to quantify the changes of adenoids and tonsils following RPE. RPE treatment can be considered as a valid and effective treatment option for pediatric OSA population with narrow high arch palate and adenotonsillar hypertrophy.

  View details for DOI 10.1016/j.sleep.2022.02.011

  View details for PubMedID 35390750

• A Minimally Invasive Nasal Endoscopic Approach to Distraction Osteogenesis Maxillary Expansion to Restore Nasal Breathing for Adults with Narrow Maxilla. Facial plastic surgery & aesthetic medicine Liu, S. Y., Ibrahim, B., Abdelwahab, M., Chou, C., Capasso, R., Yoon, A. 2022

  Abstract

  Background: Patients with narrow high-arch palate present with limited response to standard septal, turbinate, and valve procedures for nasal obstruction. Objective: To measure the effectiveness of minimally invasive nasal endoscopic (MINE) Lefort I osteotomy among subjects with narrow high-arched palate in managing nasal obstruction. Methods: Prospective cohort study was performed where subjects with narrow high-arched palate underwent MINE distraction osteogenesis maxillary expansion (DOME) from August 2019 to January 2021. Nasal obstruction symptom evaluation (NOSE) score, mean time to opioid cessation, and mean duration of cranial nerve V2 hypoesthesia were evaluated. Results: Among 12 subjects, the. mean NOSE score decreased from 58.89 to 15.83 (p=0.004). There were no complaints of lip mobility or deformity. Conclusion: MINI-DOME can reduce nasal obstruction in a certain phenotype of patients and further improve patient-centric outcomes by limiting the approach to the Lefort I osteotomy to an endoscopic nasal approach.

  View details for DOI 10.1089/fpsam.2021.0154

  View details for PubMedID 35179990

• Determinants of Sleep-Disordered Breathing During the Mixed Dentition: Development of a Functional Airway Evaluation Screening Tool (FAIREST-6). Pediatric dentistry Oh, J. S., Zaghi, S., Peterson, C., Law, C. S., Silva, D., Yoon, A. J. 2021; 43 (4): 262-272

  Abstract

  Purpose: The purpose of this study was to identify patterns of functional, extraoral, and intraoral examination characteristics that correlate with increased risk of sleep disturbances and develop a functional airway screening tool to help clinicians for early diagnosis of pediatric sleep-disordered breathing. Methods: From March 2018 until March 2019, a cross-sectional study was conducted of 96 mixed dentition children during dental examinations at the UCLA pediatric dental clinic. Outcome measures included a sleep index score by the Sleep Disturbance Scale for Children (SDSC) completed by parents. Clinical assessment tool measurements assessing functional, extraoral, intraoral soft tissue, and intraoral hard tissue determinants were recorded during a routine dental examination by pediatric dental residents. Results: The mean age was 8.9 years (±1.9 years standard deviation), with 46 males and 50 females participating. Mouth-breathing (functional), mentalis strain (extra-oral), tonsillar hypertrophy and ankyloglossia (intraoral soft tissue), dental wear, and narrow palate (intraoral hard tissue) were found to be the most clinically deterministic of higher SDSC scores (P<0.01). A clinical assessment tool for sleep-disordered breathing in pediatric dental patients (FAIREST-6) was developed, comprising these six clinical factors. Conclusions: The FAIREST-6 is a concise and validated clinical assessment tool that may aid in early diagnosis and intervention of pediatric sleep-disordered breathing.

  View details for PubMedID 34467840

• Determinants of Sleep-Disordered Breathing During the Mixed Dentition: Development of a Functional Airway Evaluation Screening Tool (FAIREST-6) PEDIATRIC DENTISTRY Oh, J. S., Zaghi, S., Peterson, C., Law, C. S., Silva, D., Yoon, A. J. 2021; 43 (4): 262-+

  View details for Web of Science ID 000691750700004

• Assessment of posterior tongue mobility using lingual-palatal suction: Progress towards a functional definition of ankyloglossia JOURNAL OF ORAL REHABILITATION Zaghi, S., Shamtoob, S., Peterson, C., Christianson, L., Valcu-Pinkerton, S., Peeran, Z., Fung, B., Ng, D., Jagomagi, T., Archambault, N., O'Connor, B., Winslow, K., Lano, M., Murdock, J., Morrissey, L., Yoon, A. 2021; 48 (6): 692-700

  Abstract

  A functional definition of ankyloglossia has been based on assessment of tongue mobility using the tongue range of motion ratio (TRMR) with the tongue tip extended towards the incisive papilla (TIP). Whereas this measurement has been helpful in assessing for variations in the mobility of the anterior one-third of the tongue (tongue tip and apex), it may be insufficient to adequately assess the mobility of the posterior two-thirds body of the tongue. A commonly used modification is to assess TRMR while the tongue is held in suction against the roof of the mouth in lingual-palatal suction (LPS).This study aims to explore the utility and normative values of TRMR-LPS as an adjunct to functional assessment of tongue mobility using TRMR-TIP.Cross-sectional cohort study of 611 subjects (ages: 3-83 years) from the general population.Measurements of tongue mobility using TRMR were performed with TIP and LPS functional movements. Objective TRMR measurements were compared with subjective self-assessment of resting tongue position, ease or difficulty elevating the tongue tip to the palate, and ease or difficulty elevating the tongue body to the palate.There was a statistically significant association between the objective measures of TRMR-TIP and TRMR-LPS and subjective reports of tongue mobility. LPS measurements were much more highly correlated with differences in elevating the posterior body of the tongue as compared to TIP measurements (R2 0.31 vs 0.05, P < .0001).This study validates the TRMR-LPS as a useful functional metric for assessment of posterior tongue mobility.

  View details for DOI 10.1111/joor.13144

  View details for Web of Science ID 000608028800001

  View details for PubMedID 33386612

• Determinants of probable sleep bruxism in a pediatric mixed dentition population: a multivariate analysis of mouth vs. nasal breathing, tongue mobility, and tonsil size SLEEP MEDICINE Oh, J. S., Zaghi, S., Ghodousi, N., Peterson, C., Silva, D., Lavigne, G. J., Yoon, A. J. 2021; 77: 7-13

  Abstract

  This study aims to identify structural and functional craniofacial characteristics that correlate with higher incidence of 'probable' sleep bruxism in children.From March 2018 until March 2019, a cross-sectional clinical study was performed with ninety-six healthy children ages 6-12 years who presented for routine dental examination at the UCLA pediatric dental clinic. Variables of interest included: (1) assessment of probable bruxism based on parental awareness on the frequency of tooth grinding during sleep and clinical signs of bruxism based on tooth wear; (2) parental reports of mouth breathing while awake and asleep, snoring during sleep, difficulty breathing and/or gasping for air during sleep; (3) parental reports of psychosocial distress; (4) assessment of tonsil hypertrophy, tongue mobility, and nasal obstruction. Three pediatric dental residents were calibrated to perform the clinical data collection. All dental residents were graduated dentists with licensure and at least one year of experience examining children. The methodology to take the specific measurements administered in the manuscript were calibrated between the data-collectors under the supervision of a board-certified pediatric dentist and orthodontist (AY).The mean age of individuals was 8.9 (SD = 1.9) years with a gender distribution of 46 males and 50 females. There were 23 out of the 96 (24%) individuals who met the diagnostic criteria for probable sleep bruxism (PSB). Sleep Disturbance Scale for Children (SDSC) scores were significantly elevated among children positive for PSB, indicating that they are at higher risk for sleep disturbances (PSB-positive: 45.1 ± 13.0, PSB-negative: 34.8 ± 5.5; p < 0.0001). Impaired nasal breathing, parental reports of mouth breathing when awake or asleep, restricted tongue mobility, and tonsillar hypertrophy were found to be significant risk factors for PSB. Exploratory analysis further suggests a synergistic effect between tonsil hypertrophy, restricted tongue mobility, and nasal obstruction. The incidence of probable sleep bruxism among individuals without any of the exam findings of tonsillar hypertrophy, restricted tongue mobility, and nasal obstruction was 5/58 (8.6%), whereas the incidence of PSB among individuals with all three exam findings was 10/11 (90.9%), p < 0.0001. Among the 23 individuals with PSB, however, there were n = 5 (21.7%) who did not have any of the three exam findings, suggesting an additional role of psychosocial distress, postural maladaptation, malocclusion, or other factors in the etiology of sleep bruxism.This study shows that tonsil hypertrophy, restricted tongue mobility, and nasal obstruction may have a synergistic association on the presentation of PSB. Dentists should evaluate for tonsillar hypertrophy, restricted tongue mobility, and nasal obstruction in the evaluation of PSB, as these exam findings are highly prevalent in the majority of cases.

  View details for DOI 10.1016/j.sleep.2020.11.007

  View details for Web of Science ID 000618554500002

  View details for PubMedID 33291022

• Impact of rapid palatal expansion on the internal nasal valve and obstructive nasal symptoms in children SLEEP AND BREATHING Yoon, A., Abdelwahab, M., Liu, S., Oh, J., Suh, H., Trieu, M., Kang, K., Silva, D. 2020

  Abstract

  The aim of this study is to evaluate the impact of rapid palatal expansion (RPE) on the nasal airway subjectively by utilizing patient-reported outcome measures (PROM) and objectively by evaluating validated internal nasal valve (INV) measurements obtained from cone beam computed tomography (CBCT) in pediatrics.In this retrospective cohort study, subjects who underwent RPE from March to December 2018 with cone beam CT and Nasal Obstruction Symptom Evaluation (NOSE) scores were included. Exclusion criteria included craniofacial deformity, allergies, asthma, recent nasal trauma, or surgery. INV measurements (angle and cross-sectional area), diastema, midpalatal suture opening, and NOSE scores were evaluated.Fifty-one subjects met the inclusion criteria with a mean age of 10.1 ± 2.6. Pre-expansion mean NOSE score was 32.55 (moderate) while post-expansion was 13.92 (mild). Mean NOSE score improved significantly by an average of 18.63 following post-expansion (P < 0.0001). The patients' right and left INV angles increased significantly by a mean of 2.42° and 2.65° respectively (P < 0.0001). Right and left INV cross-sectional areas increased significantly by an average of 14.35 mm2 (P < 0.0001) and 14.17 mm2 (P < 0.0001) respectively. An average expansion of the diastema and the suture was 1.60 mm and 3.05 mm respectively (P < 0.0001), with an average of 6.29 mm of expansion. We found the amount of diastema expansion to correlate with change in NOSE score (R = - 0.32, P = 0.022). Age and diastema showed a negative correlation (R = - 0.44, P = 0.0019), while INV angle and diastema showed a statistically significant positive correlation (R = 0.28, P = 0.048).RPE showed improvement in both NOSE scores and objective measures of the INV. This may show the possibility of considering RPE in managing resistant pediatric nasal airways. Future studies should include collaboration with pediatric otolaryngologists, with the inclusion of pediatric patients with persistent nasal obstruction.

  View details for DOI 10.1007/s11325-020-02140-y

  View details for Web of Science ID 000546893500002

  View details for PubMedID 32648185

• How does distraction osteogenesis maxillary expansion (DOME) reduce severity of obstructive sleep apnea? Sleep & breathing = Schlaf & Atmung Iwasaki, T., Yoon, A., Guilleminault, C., Yamasaki, Y., Liu, S. Y. 2019

  Abstract

  OBJECTIVE: Distraction osteogenesis maxillary expansion (DOME) is a reliable method to expand the nasal floor and hard palatal vault in adults with obstructive sleep apnea (OSA). DOME results in a reduction in the apnea-hypopnea index (AHI) and subjective report of improved nasal breathing. Using rhinomanometry augmented computational fluid dynamic (CFD) modeling, we propose a mechanism of how DOME reduces upper airway pharyngeal collapse in adults with OSA.MATERIAL AND METHOD: A retrospective cohort with 20 subjects and mean age of 29.6 ± 8 years who completed DOME at Stanford University from September 2014 to April 2016. Subjects were included if polysomnography, airway morphology, and rhinomanometry were available for use. From the CBCT data, 3D nasal and pharyngeal airway model were generated. Numeric CFD simulation of the airway models were analyzed under the following conditions: (1) the volume of air was flowing at a velocity of 300 cm3/s, (2) the wall surface was not slippery, and (3) the simulations were repeated 1000 times to calculate mean values. Statistical analyses using SPSS v24 software included paired t tests, nonparametric Wilcoxon rank test, Friedman test with Bonferroni correction, and Spearman's correlation coefficients (p < 0.05).RESULTS: Mean AHI improved from 17.8 ± 17.6 to 7.8 ± 7.1 events per hour (p < 0.001). Mean lowest oxygen saturation improved from 88.2 ± 7.2 to 90.9 ± 4.2% (p < 0.05). Mean airflow velocity within the nasal airway decreased from 15.6 ± 7.3 to 7.4 ± 2.1 m/s (p < 0.001) after DOME. Mean negative pressure of the nasal airway, retropalatal airway, oropharyngeal airway, and hypopharyngeal airway is reduced from - 158.4 ± 115.3 to - 48.6 ± 28.7 Pa, from - 174.8 ± 119.9 to - 52.5 ± 31.3 Pa, from - 177.0 ± 118.4 to - 54.9 ± 31.8 Pa and from - 177.9 ± 117.9 to - 56.9 ± 32.1 Pa (p < 0.001), respectively. AHI positively correlated with nasal flow velocity (p < 0.05) and negatively correlated with pharyngeal airway pressure (p < 0.05). ODI was positively correlated with nasal velocity (p < 0.05) and negatively correlated with nasal airway pressure (p < 0.05), retropalatal airway pressure (p < 0.001), oropharyngeal airway pressure (p < 0.001), and hypopharyngeal airway pressure (p < 0.05).CONCLUSION: Anatomic expansion of the nasal floor with widening of the hard palatal vault from DOME is associated with reduction of nasal airflow velocity and downstream reduction of negative pressure in the pharyngeal airway. This dynamic interaction correlates with a reduction in the apnea-hypopnea index (AHI) and Oxygen Desaturation Index (ODI).

  View details for DOI 10.1007/s11325-019-01948-7

  View details for PubMedID 31823220

• Distraction Osteogenesis Maxillary Expansion (DOME) for adult obstructive sleep apnea patients with narrow maxilla and nasal floor. Sleep medicine Yoon, A., Guilleminault, C., Zaghi, S., Liu, S. Y. 2019

  Abstract

  OBJECTIVES: This study correlates objective and subjective measurements associated with obstructive sleep apnea (OSA) to define the efficacy of Distraction Osteogenesis Maxillary Expansion (DOME) to treat adult OSA patients with narrow maxilla and nasal floor.METHODS: This is a retrospective study reviewing cases from September 2014 through April 2018 with 75 eligible subjects. Inclusion criteria required OSA confirmed by attended polysomnography (PSG). Pre- and Post-operative clinical data were measured at the Stanford Sleep Medicine and Stanford Sleep Surgery Clinics. DOME is a two-step process starting with insertion of custom-fabricated maxillary expanders anchored to the hard palate by mini-implants followed by minimally invasive osteotomies. After maxillary expansion was complete, orthodontic treatment to restore normal occlusion was initiated. Perioperative Apnea-Hypopnea Index (AHI), Epworth Sleepiness Scale (ESS), Nasal Obstruction Symptom Evaluation (NOSE), and Oxygen Desaturation Index (ODI) were measured for 43, 72, 72, and 34 subjects respectively. Statistical analysis was performed using paired T-test with significance set at p-value < 0.05.RESULTS: The mean age of test subjects was 30.5±8.5 years with a gender distribution of 57 males and 18 females. There was a significant reduction in pre and post-operative NOSE score (10.94±5.51 to 3.28±2.89, p<0.0001), mean ESS score (10.48±5.4 to 6.69±4.75, p<0.0001), and AHI (17.65±19.30 to 8.17±8.47, p<0.0001) with an increased percentage of REM sleep (14.4±8.3% to 22.7±6.6%, p=0.0014). No significant adverse effects were identified.CONCLUSIONS: DOME treatment reduced the severity of OSA, refractory nasal obstruction, daytime somnolence, and increased the percentage of REM sleep in this selected cohort of adults OSA patients with narrow maxilla and nasal floor.

  View details for DOI 10.1016/j.sleep.2019.06.002

  View details for PubMedID 31606311

• Impact of Distraction Osteogenesis Maxillary Expansion on the Internal Nasal Valve in Obstructive Sleep Apnea. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Abdelwahab, M., Yoon, A., Okland, T., Poomkonsarn, S., Gouveia, C., Liu, S. Y. 2019: 194599819842808

  Abstract

  OBJECTIVE: To assess the effect of distraction osteogenesis maxillary expansion (DOME) on objective parameters of the internal nasal valve and correlate findings with subjective outcomes.STUDY DESIGN: Retrospective cohort study.SETTING: Tertiary referral center.SUBJECTS AND METHODS: After Institutional Review Board approval, included subjects were those with obstructive sleep apnea, had undergone DOME from September 2014 to April 2018, and had cone beam computed tomography scans available before and after expansion. Measurement of the internal nasal valve parameters was performed with Invivo6 Software (version 6.0.3). Interrater reliability of all pre- and postexpansion parameters was measured. Patient-reported outcome measures included the Nasal Obstruction and Septoplasty Effectiveness Scale (NOSE) and Epworth Sleepiness Scale scores, and correlation between objective and subjective outcomes were evaluated by Spearman correlation analysis.RESULTS: Thirty-two subjects met inclusion criteria. All showed significant improvement in their subjective outcomes as well as an increase in their internal valve parameters. Significant correlation was observed between increased angles and improvement in postexpansion NOSE score (right angle, P = .024; left angle, P = .029).CONCLUSION: DOME widens the internal nasal valve objectively (dimensions), which correlates significantly with subjective improvement (NOSE scores).

  View details for PubMedID 31084256

• Toward a functional definition of ankyloglossia: validating current grading scales for lingual frenulum length and tongue mobility in 1052 subjects. Sleep & breathing = Schlaf & Atmung Yoon, A., Zaghi, S., Weitzman, R., Ha, S., Law, C. S., Guilleminault, C., Liu, S. Y. 2017

  Abstract

  Alterations of the lingual frenulum may contribute to oromyofacial dysfunction, speech and swallowing impediments, underdevelopment of the maxillofacial skeleton, and even predispose to sleep breathing disorder. This study aims to assess the utility of existing instruments for evaluation of restricted tongue mobility, describe normal and abnormal ranges of tongue mobility, and provide evidence in support of a reliable and efficient measure of tongue mobility.A prospective cohort study of 1052 consecutive patients was evaluated during a 3-month period. Age, gender, ethnicity, height, weight, BMI, maximal interincisal mouth opening (MIO), mouth opening with tongue tip to maxillary incisive papillae at roof of mouth (MOTTIP), Kotlow's free-tongue measurement, and presence of severe tongue-tie were recorded. Secondary outcome measures include tongue range of motion deficit (TRMD, difference between MIO and MOTTIP) and tongue range of motion ratio (TRMR, ratio of MOTTIP to MIO).Results indicate that MIO is dependent on age and height; MOTTIP and TRMD are dependent on MIO; Kotlow's free-tongue measurement is an independent measure of free-tongue length and tongue mobility. TRMR is the only independent measurement of tongue mobility that is directly associated with restrictions in tongue function.We propose the use of tongue range of motion ratio as an initial screening tool to assess for restrictions in tongue mobility. "Functional" ankyloglossia can thus be defined and treatment effects followed objectively by using the proposed grading scale: grade 1: tongue range of motion ratio is >80%, grade 2 50-80%, grade 3 < 50%, grade 4 < 25%.

  View details for DOI 10.1007/s11325-016-1452-7

  View details for PubMedID 28097623

• Distraction Osteogenesis Maxillary Expansion (DOME) for Adult Obstructive Sleep Apnea Patients with High Arched Palate. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Liu, S. Y., Guilleminault, C. n., Huon, L. K., Yoon, A. n. 2017; 157 (2): 345–48

  Abstract

  A narrow maxilla with high arched palate characterizes a phenotype of obstructive sleep apnea (OSA) patients that is associated with increased nasal resistance and posterior tongue displacement. Current maxillary expansion techniques for adults are designed to correct dentofacial deformity. We describe distraction osteogenesis maxillary expansion (DOME) tailored to adult patients with OSA with narrow nasal floor and high arched palate without soft tissue redundancy. DOME is performed with placement of maxillary expanders secured by mini-implants along the midpalatal suture. This minimizes the maxillary osteotomies necessary to re-create sutural separation for reliable expansion at the nasal floor and palatal vault. We report the safety and efficacy profile of the first 20 patients at Stanford who underwent DOME.

  View details for PubMedID 28675100

• Ankyloglossia as a risk factor for maxillary hypoplasia and soft palate elongation: A functional - morphological study. Orthodontics & craniofacial research Yoon, A. J., Zaghi, S. n., Ha, S. n., Law, C. S., Guilleminault, C. n., Liu, S. Y. 2017; 20 (4): 237–44

  Abstract

  To characterize associations between restricted tongue mobility and maxillofacial development.Cross-sectional cohort study of 302 consecutive subjects from an orthodontic practice.Tongue mobility (measured with tongue range of motion ratio [TRMR] and Kotlow free tongue measurement) was correlated with measurements of the maxillofacial skeleton obtained from dental casts and cephalometric radiographs.Tongue range of motion ratio and Kotlow measures of restricted tongue mobility were associated with (i) ratio of maxillary intercanine width to canine arch length, (ii) ratio of maxillary intermolar width to canine arch length and (iii) soft palate length. Restricted tongue mobility was not associated with hyoid bone position or Angle's skeletal classification.Restricted tongue mobility was associated with narrowing of the maxillary arch and elongation of the soft palate in this study. These findings suggest that variations in tongue mobility may affect maxillofacial development.

  View details for PubMedID 28994495

• Perinatal intermittent hypoxia alters gamma-aminobutyric acid: a receptor levels in rat cerebellum INTERNATIONAL JOURNAL OF DEVELOPMENTAL NEUROSCIENCE Pae, E., Yoon, A. J., Ahuja, B., Lau, G. W., Nguyen, D. D., Kim, Y., Harper, R. M. 2011; 29 (8): 819-826

  Abstract

  Perinatal hypoxia commonly causes brain injury in infants, but the time course and mechanisms underlying the preferential male injury are unclear. Intermittent hypoxia disturbs cerebellar γ-aminobutyric (GABA)-A receptor profiles during the perinatal period, possibly responding to transient excitatory processes associated with GABA(A) receptors. We examined whether hypoxic insults were particularly damaging to the male rodent cerebellum during a specific developmental time window. We evaluated cerebellar injury and GABA(A) receptor profiles following 5-h intermittent hypoxia (IH: 20.8% and 10.3% ambient oxygen, switched every 240s) or room-air control in groups of male and female rat pups on postnatal d 1-2, wk 1, or wk 3. The cerebella were harvested and compared between groups. The mRNA levels of GABA(A) receptors α6, normalized to a house-keeping gene GAPDH, and assessed using real-time reverse-transcriptase PCR assays were up-regulated by IH at wk 1, more extensively in male rats, with sex influencing the regulatory time-course. In contrast, GABA(A) α6 receptor protein expression levels, assessed using Western blot assays, reached a nadir at wk 1 in both male and female rats, possibly indicating involvement of a post-transcriptional mechanism. The extent of cerebellar damage and level of apoptosis, assessed by DNA fragmentation, were greatest in the wk 3 IH-exposed group. The findings suggest partial protection for female rats against early hypoxic insult in the cerebellum, and that down-regulation of GABA(A) receptors, rather than direct neural injury assessed by DNA fragmentation may modify cerebellar function, with potential later motor and other deficits.

  View details for DOI 10.1016/j.ijdevneu.2011.09.003

  View details for Web of Science ID 000297775100005

  View details for PubMedID 21964325

• In response to the Letter to the Editor regarding "A roadmap of craniofacial growth modification for children with sleep-disordered breathing: a multidisciplinary proposal". Sleep Yoon, A., Gozal, D., Pelayo, R., Kushida, C., Liu, S., Hong, C. 2023

  View details for DOI 10.1093/sleep/zsad163

  View details for PubMedID 37358845

• Feasibility of Distraction Osteogenesis Maxillary Expansion (DOME) in patients with persistent nasal obstruction after septoplasty. International forum of allergy & rhinology Liu, S. Y., Yoon, A., Abdelwahab, M., Yu, M. S. 1800

  Abstract

  BACKGROUND: Distraction osteogenesis maxillary expansion (DOME) is an emerging surgical concept for obstructive sleep apnea patients presenting with nasal obstruction, with a high-arched and narrow hard palate. We demonstrate the feasibility of DOME in the treatment of patients with persistent nasal obstruction after primary septoplasty.METHODS: A total of 32 consecutive patients with persistent nasal obstruction after septoplasty who underwent DOME were enrolled in this study. The efficacy of DOME in treating persistent nasal obstruction in septoplasty failure patients was evaluated by using the validated Nasal Obstruction Symptom Evaluation (NOSE) scale. Pre- and postoperative computed tomography (CT) scans were performed to measure the change of nasal floor width after surgery.RESULTS: The NOSE score significantly improved from 13.62±4.74 to 5.15±3.50 (p<0.001) after DOME. The postoperative CT scan showed a significant increase of the nasal floor width from 22.4±4.21 to 28.06±4.52 (p<0.01). No patient experienced major complications, such as wound infection, oronasal fistula, sinusitis, loss of incisor teeth, and malunion.CONCLUSIONS: This study shows that DOME appears to improve persistent nasal obstruction after septoplasty in patients with narrow and high-arched hard palate. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1002/alr.22931

  View details for PubMedID 34919340

• Correcting Maxillary Molar Root Angulation with the Biocreative System. Journal of clinical orthodontics : JCO Yoon, A., Noh, M. K., Moon, H. W., Chung, K. R., Kim, S. H. 2020; 53 (10): 588-601

  View details for PubMedID 32058325

• Lingual frenuloplasty with myofunctional therapy: Exploring safety and efficacy in 348 cases. Laryngoscope investigative otolaryngology Zaghi, S., Valcu-Pinkerton, S., Jabara, M., Norouz-Knutsen, L., Govardhan, C., Moeller, J., Sinkus, V., Thorsen, R. S., Downing, V., Camacho, M., Yoon, A., Hang, W. M., Hockel, B., Guilleminault, C., Liu, S. Y. 2019; 4 (5): 489-496

  Abstract

  Ankyloglossia is a condition of altered tongue mobility due to the presence of restrictive tissue between the undersurface of the tongue and the floor of mouth. Potential implications of restricted tongue mobility (such as mouth breathing, snoring, dental clenching, and myofascial tension) remain underappreciated due to limited peer-reviewed evidence. Here, we explore the safety and efficacy of lingual frenuloplasty and myofunctional therapy for the treatment of these conditions in a large and diverse cohort of patients with restricted tongue mobility.Four hundred twenty consecutive patients (ages 29 months to 79 years) treated with myofunctional therapy and lingual frenuloplasty for indications of mouth breathing, snoring, dental clenching, and/or myofascial tension were surveyed. All procedures were performed by a single surgeon using a scissors and suture technique. Safety and efficacy was assessed >2 months postoperatively by means of patient-reported outcome measures.In all, 348 surveys (83% response rate) were completed showing 91% satisfaction rate and 87% rate of improvement in quality of life through amelioration of mouth breathing (78.4%), snoring (72.9%), clenching (91.0%), and/or myofascial tension (77.5%). Minor complications occurred in <5% of cases including complaints of prolonged pain or bleeding, temporary numbness of the tongue-tip, salivary gland issues, minor wound infection or inflammation, and need for revision to excise scar tissue. There were no major complications.Lingual frenuloplasty with myofunctional therapy is safe and potentially effective for the treatment of mouth breathing, snoring, clenching, and myofascial tension in appropriately selected patient candidates. Further studies with objective measures are merited.3.

  View details for DOI 10.1002/lio2.297

  View details for PubMedID 31637291

  View details for PubMedCentralID PMC6793603

• Lingual frenuloplasty with myofunctional therapy: Exploring safety and efficacy in 348 cases LARYNGOSCOPE INVESTIGATIVE OTOLARYNGOLOGY Zaghi, S., Valcu-Pinkerton, S., Jabara, M., Norouz-Knutsen, L., Govardhan, C., Moeller, J., Sinkus, V., Thorsen, R. S., Downing, V., Camacho, M., Yoon, A., Hang, W. M., Hockel, B., Guilleminault, C., Liu, S. 2019

  View details for DOI 10.1002/lio2.297

  View details for Web of Science ID 000482692400001

• Impact of Distraction Osteogenesis Maxillary Expansion on the Internal Nasal Valve in Obstructive Sleep Apnea OTOLARYNGOLOGY-HEAD AND NECK SURGERY Abdelwahab, M., Yoon, A., Okland, T., Poomkonsarn, S., Gouveia, C., Liu, S. 2019; 161 (2): 362–67

  View details for DOI 10.1177/0194599819842808

  View details for Web of Science ID 000478631500023

• Optimizing mandibular sagittal split of large maxillomandibular advancements for obstructive sleep apnea: patient and surgical factors. Clinical oral investigations Chen, Y. F., Ko, E. C., Zaghi, S., Yoon, A., Williams, R., Riley, R., Liu, S. Y. 2019

  Abstract

  OBJECTIVES: Maxillomandibular advancement (MMA) confers consistent and high rates of surgical success for obstructive sleep apnea (OSA). In the era of value-based medicine, identifying factors that affect the stability of rigid fixation and allow rapid return to function are important targets for improvement. The aim of this study was to identify patient and surgical factors associated with mandibular sagittal split outcomes associated with optimal postoperatively skeletal stability.STUDY DESIGN: Retrospective cohort study.MATERIALS AND METHODS: Forty-six subjects (43 males and 3 females) with postoperative CT scans including three-dimensional reconstruction from which mandibular split patterns could be analyzed were enrolled. Patient factors (age and polysomnographic measures) and surgical factors (extent of osteotomy prior to controlled fracture) were assessed. Outcome measures include (1) bone thickness for rigid fixation and (2) area of passive bony overlap after advancement.RESULTS: Age and severity of disease did not contribute significantly to optimal mandibular split patterns. For optimal area for passive bony overlap and thickness of buccal and lingual plates for rigid fixation, the most important factors are related to surgical technique.CONCLUSIONS: Anterior osteotomy just to the midline of inferior border and horizontal osteotomy to the mandibular foramen are associated with split patterns that result in optimal rigid fixation and passive bony overlap for OSA patients undergoing MMA.CLINICAL RELEVANCE: Optimal surgical technique has the most significant influence in allowing rapid return to function after MMA in patients with OSA.

  View details for DOI 10.1007/s00784-019-03017-5

  View details for PubMedID 31332567

• Surgery in Adults CURRENT CONCEPTS OF SLEEP APNEA SURGERY Blumen, M., Sommer, U., Verse, T., Hamans, E., Liu, S., Guilleminault, C., Yoon, A., Verse, T., DeVries, N. 2019: 147–258

  View details for Web of Science ID 000561991900009

• Efficacy of Maxillomandibular Advancement Examined with Drug-Induced Sleep Endoscopy and Computational Fluid Dynamics Airflow Modeling. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Liu, S. Y., Huon, L., Iwasaki, T., Yoon, A., Riley, R., Powell, N., Torre, C., Capasso, R. 2016; 154 (1): 189-195

  Abstract

  To use drug-induced sedation endoscopy (DISE) and computational fluid dynamics (CFD) modeling to study dynamic airway and airflow changes after maxillomandibular advancement (MMA), and how the changes correlate with surgical success based on polysomnography parameters.Retrospective cohort study.University medical center.DISE was rated with the VOTE (velum, oropharynx, tongue, epiglottis) classification, and CFD was used to model airflow velocity and negative pressure exerted on pharyngeal wall. Changes in VOTE score by site and CFD measurements were correlated with perioperative polysomnography outcomes of apnea-hypopnea index (AHI), apnea index (AI), oxygenation desaturation index (ODI), and lowest oxygen saturation.After MMA, 20 subjects (17 males, 3 females) with a mean age of 44 ± 12 years and body mass index of 27.4 ± 4.6 kg/m(2) showed mean decreases in AHI (53.6 ± 26.6 to 9.5 ± 7.4 events/h) and ODI (38.7 ± 30.3 to 8.1 ± 9.2 events/h; P < .001). Improvement in lateral pharyngeal wall collapse during DISE based on VOTE score correlated with the most decrease in AHI (60.0 ± 25.6 to 7.5 ± 3.4 events/h) and ODI (46.7 ± 29.8 to 5.3 ± 2 events/h; P = .002). CFD modeling showed significant positive Pearson correlations between reduction of retropalatal airflow velocity and AHI (r = 0.617, P = .04) and ODI (r = 0.773, P = .005).AHI and ODI improvement after MMA is best correlated with (1) decreased retropalatal airflow velocity modeled by CFD and (2) increased lateral pharyngeal wall stability based on VOTE scoring from DISE.

  View details for DOI 10.1177/0194599815611603

  View details for PubMedID 26740522

• Efficacy of Maxillomandibular Advancement Examined with Drug-Induced Sleep Endoscopy and Computational Fluid Dynamics Airflow Modeling OTOLARYNGOLOGY-HEAD AND NECK SURGERY Liu, S. Y., Huon, L., Iwasaki, T., Yoon, A., Riley, R., Powell, N., Torre, C., Capasso, R. 2016; 154 (1): 189-195

  Abstract

  To use drug-induced sedation endoscopy (DISE) and computational fluid dynamics (CFD) modeling to study dynamic airway and airflow changes after maxillomandibular advancement (MMA), and how the changes correlate with surgical success based on polysomnography parameters.Retrospective cohort study.University medical center.DISE was rated with the VOTE (velum, oropharynx, tongue, epiglottis) classification, and CFD was used to model airflow velocity and negative pressure exerted on pharyngeal wall. Changes in VOTE score by site and CFD measurements were correlated with perioperative polysomnography outcomes of apnea-hypopnea index (AHI), apnea index (AI), oxygenation desaturation index (ODI), and lowest oxygen saturation.After MMA, 20 subjects (17 males, 3 females) with a mean age of 44 ± 12 years and body mass index of 27.4 ± 4.6 kg/m(2) showed mean decreases in AHI (53.6 ± 26.6 to 9.5 ± 7.4 events/h) and ODI (38.7 ± 30.3 to 8.1 ± 9.2 events/h; P < .001). Improvement in lateral pharyngeal wall collapse during DISE based on VOTE score correlated with the most decrease in AHI (60.0 ± 25.6 to 7.5 ± 3.4 events/h) and ODI (46.7 ± 29.8 to 5.3 ± 2 events/h; P = .002). CFD modeling showed significant positive Pearson correlations between reduction of retropalatal airflow velocity and AHI (r = 0.617, P = .04) and ODI (r = 0.773, P = .005).AHI and ODI improvement after MMA is best correlated with (1) decreased retropalatal airflow velocity modeled by CFD and (2) increased lateral pharyngeal wall stability based on VOTE scoring from DISE.

  View details for DOI 10.1177/0194599815611603

  View details for Web of Science ID 000367745700028