This study explored the relationship between malocclusion and signs and symptoms of temporomandibular disorders (TMD) in 124 patients with severe Class II malocclusion, before and 2 years after bilateral sagittal split osteotomy (BSSO). Patients were evaluated with the Craniomandibular Index (CMI), the Peer Assessment Rating Index (PAR Index, to assess gross changes in the occlusion), and symptom questionnaires. The results showed a significant improvement in occlusion; PAR Index scores dropped from a mean of 18.1 before surgery to a mean of 6.1 at 2 years postsurgery (P 0.001). The CMI and masticatory index (MI) for muscle pain indicated clinically small but statistically significant improvement (P = 0.0001) from before surgery (mean CMI = 0.14, mean MI = 0.15) to after surgery (mean CMI = 0.10, mean MI = 0.08). The number of patients with clikcing upon opeining decreased significantly from 33 (26.6%) to 13 (10.5%) (P = 0.001). However, the number of patients with fine crepitus increased from 5 (4.0%) before surgery to 16 (12.9%) at 2 years postsurgery (P = 0.005). Significant reductions in subjective pain and discomfort were also found 2 years after surgery. The magnitude of change in muscular pain was not related to the severity of the pretreatment malocclusion, a finding that suggests that factors other than malocclusion may be respondible for the change in TMD.