Predictability, skeletal stability, and safety of iliac crest bone grafts in large maxillary advancement with Le Fort I osteotomy: a systematic review

Objective: The aim of this systematic review was to evaluate the skeletal stability, predictability, and safety of using autogenous iliac crest bone grafts during large maxillary advancement performed with Le Fort I osteotomy. Methods: A systematic literature search was conducted in November 2025 using PubMed, Scopus, Embase, Web of Science, and WorldCat databases. Clinical studies reporting large maxillary advancement performed with Le Fort I osteotomy and incorporating autogenous iliac crest bone grafts were included. Study selection followed PRISMA guidelines. Data extraction focused on the magnitude of maxillary advancement, surgical protocols, stabilization methods, skeletal stability, relapse patterns, graft integration, implant-related outcomes, and complications. Methodological quality was assessed using the Mixed-Methods Appraisal Tool (MMAT). Results: The review included clinical studies predominantly consisting of case reports, case series, and retrospective cohort studies. Autogenous iliac crest bone grafts were consistently used in complex clinical scenarios, such as severe maxillary atrophy, hypoplasia, and congenital craniofacial deformities. Large maxillary advancements were generally associated with favorable postoperative skeletal stability, with most relapse occurring during the early healing phase and minimal changes observed during long-term follow-up when rigid fixation and adequate graft integration were achieved. Interpositional grafting facilitated predictable advancement by bridging extensive osteotomy gaps. Donor-site morbidity related to iliac crest harvesting was typically mild and transient. Implant-related outcomes, reported as secondary findings, were generally favorable when implants were placed after an adequate healing period. Conclusion: Despite predominantly observational evidence, autogenous iliac crest bone grafting during large maxillary advancement with Le Fort I osteotomy appears to offer predictable advancement, acceptable skeletal stability, and a favorable safety profile, warranting further prospective investigation.