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Correction of severe malocclusions with skeletal discrepancies requires orthodontic treatment in combination with orthognathic surgery. Even though conventional orthognathic surgery (COS) is a common and well-accepted approach its influence on the signs and symptoms of temporomandibular disorders (TMDs) is still debated. Recently with the introduction of surgery first approach, a different timing for the management of dentoskeletal imbalances has been proposed. The present study is aimed at assessing the relationship between surgery first approach and temporomandibular joint (TMJ) disorders.The study sample consisted of 24 patients who were selected to be treated with surgery first approach. Clinical follow-ups after surgery were performed every week for the first month, at 3 months, 6 months, and at 1 year. A radiological follow-up was performed at 1 week and at 1 year after the operation with a panorex and a latero-lateral teleradiograph. To assess the effect of surgery first approach on the TMDs signs and symptoms, a clinical assessment was performed 4 days before surgery (T1), 6 months after surgery (T2), and 1 year postoperatively (T3).The results of the authors’ study show that pain assessment revealed a general improvement of this symptom in correspondence to TMJ and masticatory muscles except in the masseter and neck region. Also joint noises, TMJ functioning, migraine, and headache underwent a considerable improvement.Surgery first approach is an innovative orthognathic procedure and, by undergoing surgery first approach, patients with pre-existing TMJ dysfunction may experience a significant improvement or even resolution of the TMDs signs and symptoms.