This paper reports on the reconstruction of the sound-conducting system in the middle ear in those ears in which the incus and the stapes suprastructure are either absent or inadequate as after prior otitis media or tympanoplasty. When the incus is inadequate after prior stapedectomy or when the stapes suprastructure and incus are absent in congenital malformations of the middle ear, hearing restoration by ossicular reconstruction can cause problems. In cases in which the malleus head and incus are fixed in the epitympanum with the absence of the stapes suprastructure, the ossicular reconstruction will be complicated, too. In these situations, the Teflon malleus attachment piston can be useful to reconstruct the sound-conducting mechanism of the middle ear. We report our results with the malleus attachment piston in 41 operations over an 8-year period. The hearing results show that a closure of the pure-tone average air-bone gap to within 10 dB was possible in 70.7% (29/41) and to within 20 dB in 87.8% (36/41). A residual air-bone gap of > 30 dB was seen in 3 cases (7.3%). Sensorineural hearing loss ( > 10%) did not occur and there was no decline in speech discrimination.