الفهرس 
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Abstract
Several indications for the repair of the alveolar defect were recorded in the literature as the inadequate support to the erupting teeth at the cleft site, insufficient bone to allow free orthodontic movement of teeth, insufficient bone stock for implant placement, food, and fluid escape from oronasal dehiscence, lack of alar support and hypernasality of speech. (3)
Several graft materials were used for Alveolar cleft grafting; Autogenous iliac bone graft is currently considered to be the gold standard for alveolar cleft grafting. Allogenic grafts and xenografts may have some benefits as decreasing the time of surgery and donor site morbidity; however, they lack the osteogenic properties of autogenous bone. Some preparation was added to either allografts or xenografts such as Plasma rich in growth factors (PRGF), Platelet-rich plasma (PRP), and Plasma rich fibrin (PRF); however, in any comparison, the autogenous bone was more superior. (4-6)
Fat tissue is currently considered a gold standard soft tissue graft material. Coleman et al. claimed that fat graft is biocompatible, autologous in nature, integrate with donor tissues with the least complications, and rich in stem cells. (7)
The current study aims to assess the effects of the adjunctive use of autologous fat graft as a biological barrier membrane in conjunction with alveolar cleft grafting. The primary objective is to improve grafted bone quality and quantity. The secondary objective is the reduction of the rate of dehiscence.
The records included 38 cleft patients seeking Alveolar cleft grafting. 20 male patients and 18 female patients. The average age of the included patients was (Mean of 10.2 years ± 1.6years). The bone fill percentage (Bergland Scale) recorded in both the group of patients operated from 2018 and group of patients operated before 2018 showed that the bone fill was significantly better in the study group (Operated from 2018) compared to the other group (P = 0.03); the study group had 75% results having Class I fill compared to the other group which had only 50% having a class I fill. The study group had an overall statistical significance (P= 0.002) bone fill of 75 % ± 32 % bone fill compared to the control in which the bone fill was 50% ± 33 %.
The results showed that there was a significant improvement in the reduction of dehiscence in the study group (operated from 2018) compared to the group of patients operated before 2018 (P = 0.02); the study group had 3 patients out of 16 patients who had dehiscence (18.75%) compared to the other group which had 7 recurrent dehiscences out of 22 cases (31.81%).
Currently, the concept of guided bone regeneration (GBR) is considered an evidence-based approach in bone regeneration in which a barrier membrane is used to block soft tissue creeping on the grafted bone. Mixing the bone graft or covering the bone graft with biological modulating agents such as PRF or MSCs is currently an attractive research field for enhancement of Alveolar cleft grafting results. (7)
Fat graft is a successful material used in craniofacial to improve facial appearance. Fat grafts are used to recontour and give soft-tissue volume in case of craniofacial microsomia, in case of small soft tissue deficiency. The dermal fat graft was used by Bae et al. to improve the upper lip projection and lip fullness. Fat injection was used to reduce VPI by Dejonckere and van Wijngaarden. (105,108,109,115,118)
Currently, the coverage of grafts by barrier membranes presents the gold standard in grafting procedures. Guided bone regeneration (GBR) was first introduced by Dahlin et al. in 1988 as a method of bone grafting by adding a barrier membrane to prevent soft tissue creeping. Several types of membranes were proposed to be used in Guided bone regeneration; however, they can be divided into two main families, resorbable and non-resorbable membranes. The barrier membrane should be kept for 16–24 weeks for bone augmentation. The barrier membrane prevents the soft tissue from encroaching the bony grafts. (1,2,79,118, 143)
Khojasteh and Sadeghi combined Dermal fat with bone graft and compared it to conventional grafting and found that this combination improved the success of bone grafts. Khojasteh et al. combined fat with ramus graft in alveolar cleft grafting and found that fat was successful in improving the results and success of the grafting. (121)
In the current research, the late secondary alveolar cleft grafting was performed since it provides the most predictable results. Bergland scale was used to assess the success of the procedure. Currently, the Bergland scale is considered the gold standard in the evaluation of the success and failure of this procedure. In the current study, the dermal fat graft was added as a barrier membrane over the grafted bone to decrease the soft tissue creeping. The fat provides a source for mesenchymal stem cells which may improve results in addition to acting as a barrier membrane. (121,136,146)
The results showed that the addition of dermal fat graft as a barrier membrane was successful significantly in reducing the incidence of dehiscence in the study group compared to the control group in agreement with de Castro et al. The dermal fat graft was successful in reducing the graft loss in the study compared to the control in agreement with Khojasteh et al. In general, dermal fat grafting used as a barrier membrane over the grafted bone presents an easy technique, which can be used to improve the results of alveolar cleft grafting. (121,151)
Although the current study has some limitations. Primarily the lack of standardized reference for assessment because every cleft has its special orientation and configuration. In the future, authors recommend the introduction of new parameters to assess the bone fill other than the currently used Bergland Scale which measures two-dimensional fill rather than three-dimensional fill.
Conclusion:
Dermal fat graft is an available adjunctive which can be used as a biological barrier membrane to protect the grafted bone. The dermal fat graft promotes healing and increases the success of the graft because it secures the soft tissue closure, is highly biocompatible and the high MSCs content.