OBJECTIVE To determine the immediate hearing result and the long-term stability of sculpted incus interposition in ossiculoplasty and evaluate the utility of the middle ear risk index in predicting hearing outcome in these cases. METHODS One hundred thirty-seven surgical patients. METHODS Review of 137 patients who underwent ossiculoplasty using autologous or homologous sculpted incus interposition. METHODS Ossiculoplasty using autologous or homologous sculpted incus interposition. METHODS Retrospective chart review, using the guidelines delineated by the Committee on Hearing and Equilibrium of the Academy of Otolaryngology-Head and Neck Surgery for the evaluation of results for the treatment of conductive hearing loss. RESULTS The mean preoperative air bone gap was 26.8 dB, and the mean postoperative gap was 18.6 dB. Twenty-seven percent of patients were closed to within 10 dB, and 66.4% were brought to within 20 dB of the postoperative bone conduction line. Average time to the last postoperative audiometric testing was 15.8 months, with a range of 2 to 62 months. A mean air bone gap change of -0.2 dB was noted. Four patients had more than a 10 dB deterioration in conductive hearing loss. There were no cases of graft extrusion. Each ear operated upon in our series was fully scored using the middle ear risk index, and an index total was calculated. No statistical associations could be demonstrated in any group between the postoperative air bone gap and the middle ear risk index subcategories or total. CONCLUSIONS Sculpted autologous or homologous incus interposition provides hearing success comparable with current allograft prosthesis studies, has a very low extrusion rate, and remains stable over time. We were not able to demonstrate an association between the middle ear risk index and hearing results in this subset of patients.