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The significance of needle bevel orientation in
achieving a successful inferior alveolar nerve

block
Geoffrey Steinkruger, John Nusstein, Al Reader,
Mike Beck and Joel Weaver
J Am Dent Assoc 2006;137;1685-1691
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The significance of needle bevel orientation

in achieving a successful inferior alveolar
nerve block
Geoffrey Steinkruger, DMD, MS; John Nusstein, DDS, MS; Al Reader, DDS, MS;
Mike Beck, DDS, MA; Joel Weaver, DDS, PhD
NEEDLE DEFLECTION
Several authors have theorized7-9

that needle deflection is a cause of
IAN block failure. Some authors,7-12
using in vitro methods, have
reported that beveled needles,
when passed through substances of
varying densities, will deflect
toward the nonbeveled side (that
is, the needle will deflect away
from the bevel). For the IAN block,
Davidson8 recommended that the
bevel of the needle be placed away
from the mandibular ramus.
Therefore, on insertion into the
ABSTRACT
Background. The authors conducted a prospective, randomized, singleblinded, crossover study comparing the degree of pulpal anesthesia
achieved with the use of a conventional inferior alveolar nerve (IAN) block
administered with the needle bevel oriented away from the mandibular
ramus or toward the mandibular ramus.
Methods. Fifty-one blinded subjects randomly received an IAN block
injection administered with a 27-gauge needle; the needle bevel was oriented away from the mandibular ramus or oriented toward the mandibular
ramus at appointments spaced at least one week apart, in a crossover
design. The authors used a pulp tester to test molars, premolars and central
and lateral incisors for anesthesia in four-minute cycles for 60 minutes.
They considered anesthesia to be successful when two consecutive 80 readings (the maximum output on the pulp tester) were obtained within 15 minutes, and the 80 reading was sustained continuously for 60 minutes.
Results. When the needle bevel was oriented away from the mandibular
ramus, successful pulpal anesthesia from the central incisor to the second
molar was achieved in 24 to 90 percent of patients. When the needle bevel
was oriented toward the mandibular ramus, successful pulpal anesthesia
was achieved in 14 to 92 percent of patients. The results showed no significant difference between the two needle bevel orientations.
Conclusion. The authors concluded that using a 27-gauge needle with
the bevel oriented away from the mandibular ramus was similar to using
the same needle with the bevel oriented toward the mandibular ramus to
administer successful IAN blocks in adults.
Clinical Implications. For IAN blocks administered with a 27-gauge
needle, positioning the needle bevel away or toward the mandibular ramus
does not affect anesthetic success.
Key Words. Needle bevel; inferior alveolar nerve block; local anesthesia.
JADA 2006;137(12):1685-91.
Dr. Steinkruger was a graduate student in endodontics, College of Dentistry, The Ohio State University, Columbus, at the time this study was conducted. He currently has a practice limited to endodontics in Charleston, S.C.
Dr. Nusstein is an associate professor and chair, Section of Endodontics, College of Dentistry, The Ohio State University, Columbus.
Dr. Reader is a professor and program director of advanced endodontics, Section of Endodontics, College of Dentistry, The Ohio State University,
305 W. 12th Ave., Columbus, Ohio 43210, e-mail reader.2@osu.edu. Address reprint requests to Dr. Reader.
Dr. Beck is an associate professor, Section of Oral Biology, College of Dentistry, The Ohio State University, Columbus.
Dr. Weaver is a clinical professor and director of anesthesiology, Section of Oral Surgery, Oral Pathology and Anesthesiology, College of Dentistry, The Ohio State
University, Columbus.
JADA, Vol. 137 http://jada.ada.org

Copyright 2006 American Dental Association. All rights reserved.
December 2006
1685
he inferior alveolar nerve

(IAN) block is the most
frequently used
mandibular injection
technique for achieving
local anesthesia for dental treatment. However, the IAN block does
not always result in successful
pulpal anesthesia.1 Failure rates of
10 to 39 percent have been reported
in experimental studies.1 Clinical
studies in endodontics2-6 have found
that the IAN block fails between 44
and 81 percent of the time. Therefore, it would be advantageous to
improve the success rate of the IAN
block.
R E S E A R C H
1686
JADA, Vol. 137
http://jada.ada.org December 2006

SUBJECTS, MATERIALS AND METHODS

tissue, the needle will deflect toward the
mandibular ramus, allowing for a more accurate
injection.
Fifty-one adults (23 women, 28 men) aged 20 to
Hochman and Friedman9 developed a bidirec46 years (mean age, 26 years) participated in this
tional needle rotation technique designed to
study. The subjects were in good health and were
reduce needle deflection during insertion. The
not taking any medications that would alter their
bidirectional technique relies on a penlike grasp
perception of pain. The Ohio State University,
that makes it possible to rotate the needle in a
Columbus, Human Subjects Review Committee
back-and-forth-motion, similar to the rotation
approved the study, and we obtained written
described for use of endodontic hand files and
informed consent from each subject.
acupuncture. The bidirectional technique is
One of us (G.S.) administered all of the injecapplicable using the CompuDent (Milestone
tions. The 51 blinded subjects randomly received
Scientific, Livingston, N.J.) handle/needle
an IAN block injection with the needle bevel oriassembly only, because the traditional syringe
ented away from the mandibular ramus or the
cannot be rotated easily owing to the thumb ring.
needle bevel oriented toward the mandibular
Hochman and Friedman9 found that the bidirecramus at one of two separate appointments
tional needle rotation technique cancelled the
spaced at least one week apart, in a crossover
force vectors of needle insertion so the needle
design (each subject received injections with both
needle bevel orientations). All subjects received
traveled in a linear path. They also demonstrated
IAN block injections consisting of 2.2 milliliters
that a standard beveled needle that traverses 20
of 2 percent lidocaine (44 milmm of tissuelike substance can
ligrams) with 1:100,000 epinephdeflect as much as 5 mm.
No clinical study
rine (22 micrograms).
Although Hochman and
has evaluated the
Using the crossover design, the
Friedman9 found less needle deflecimportance of the
dentist administered a total of 102
tion in vitro with the bidirectional
needle bevels
injections, and each subject served
needle rotation technique, Kennedy
as his or her own control. Fiftyand colleagues5 found no significant
orientation toward
four IAN block injections were
difference in success (no pain or
the mandibular
administered on the right side and
mild pain on endodontic access or
ramus.
48 injections were administered on
instrumentation) between the bidithe left side. The side randomly
rectional rotation technique used
with an IAN block and a convenchosen for the first injection was
tional IAN block with the needle bevel oriented
used for the second injection as well. The needle
away from the mandibular ramus in patients
bevel orientation also was determined randomly.
with irreversible pulpitis. Both techniques were
The test teeth were the first and second molars,
less than 57 percent successful in achieving
first and second premolars, and lateral and cenpulpal anesthesia after an IAN block was
tral incisors. We used the contralateral canine
administered.
tooth as the unanesthetized control to ensure
Kennedy and colleagues5 conducted a study in
that the pulp tester was operating properly and
which the bevel of the needle was away from the
the subject was responding appropriately during
mandibular ramus, which theoretically would
each experimental portion of the study. Clinical
deflect the needle close to the mandibular ramus.
examinations indicated that all teeth were free
However, no clinical study, to our knowledge, has
of caries and large restorations and patients
evaluated the importance of the needle bevels
were free of periodontal disease; in addition,
orientation toward the mandibular ramus, theonone of the subjects had a history of trauma or
retically deflecting the needle away from the
tooth sensitivity.
ramus and the IAN. Therefore, the purpose of this
Before the study, one of us (G.S.) randomly
prospective, randomized, single-blinded, crossover
assigned to the two needle bevel orientations sixstudy was to compare the degree of pulpal anesdigit numbers from a random number table. Each
thesia achieved with a conventional IAN block
subject was assigned randomly to one of the two
administered with the needle bevel oriented away
needle bevel orientations to determine which was
from the mandibular ramus or toward the
to be administered at each appointment. Trained
mandibular ramus.
research assistants recorded only the random
R E S E A R C H

December 2006
1687
numbers on the data collection sheets to blind the

needle was advanced, only 1.4 mL would have
experiment.
been deposited at the target site. We wanted to
Pulp tester. At the beginning of each appointensure that a full-cartridge volume was deposited
ment and before any injections were adminisat the target site.
tered, the research assistants tested the experiAnesthetic solution. The clinician prepared
mental teeth and control contralateral canine
the anesthetic solution by removing the contents
teeth three times with a pulp tester (Kerr,
from 1.8-mL cartridges of 2 percent lidocaine with
Analytic Technology, Redmond, Wash. [now
1:100,000 epinephrine and adding 2.2 mL of lidoSybronEndo, Orange, Calif.]) to record baseline
caine to the 5-mL Luer-Lok syringe using a
vitality. After isolating the tooth to be tested with
sterile technique. All anesthetic solution carcotton rolls and drying it with gauze, the research
tridges were checked to ensure that expiration
assistant applied toothpaste to the probe tip and
dates were acceptable. The dentist administered
placed it midway between the gingival margin
0.4 mL of anesthetic solution over a 10-second
and the occlusal or incisal edge of the tooth.
period as he advanced the needle. After reaching
The current rate on the pulp tester was set for
the target area and performing aspiration, he
25 seconds and was increased from no output (0)
deposited 1.8 mL of the lidocaine solution over a
to the maximum output (80). The research
one-minute period.
assistant recorded the number associated with
One minute after the dentist administered the
the initial sensation, as reported by the patient.
IAN block, the research assistants pulp tested the
Trained research assistants performed all preinfirst and second molars. At two minutes, they
jection and postinjection tests. They
tested the first and second premowere dental or hygiene students
lars. At three minutes, they tested
specifically trained in conducting
the central and lateral incisors. At
The authors
clinical trials.
considered anesthesia four minutes, they tested the conBefore administering the IAN
to be successful when trol canine tooth. This cycle of
block, the dentist determined the
testing was repeated every four
they obtained two
proper needle bevel orientation
minutes. At every fourth cycle, the
consecutive 80
using a dental operating microscope
research assistants tested the conreadings (the
(JedMed Instrument, St. Louis).
trol tooth, the contralateral canine,
Using a black permanent marking
with a pulp tester without batteries
maximum output)
pen, he made a visual indicator (a
to test the reliability of the subjects
within 15 minutes.
dot) corresponding to the position of
responses. Every minute for 15 minthe needle bevel with respect to the
utes, the dentist asked each subject
long axis of the needle on the plastic
if his or her lip or tongue was numb.
hub of the needle assembly. The indicator was
If the research assistant did not record profound
easily visible in the mouth during the injection,
lip numbness within 15 minutes, we considered
thus enabling proper orientation of the bevel. The
the block to be unsuccessful and set up another
dentist took care to ensure that minimal needle
appointment for the subject. All testing was
rotation occurred during insertion and placement
stopped 60 minutes after the injection.
of the needle during the IAN block.
No response from the subject at the maximum
Using a cotton-tip applicator, the dentist
output (80 reading) of the pulp tester was used as
placed topical anesthetic gel (20 percent benzothe criterion for pulpal anesthesia. We considered
caine) passively at the IAN block injection site for
anesthesia to be successful when we obtained two
60 seconds. He administered a standard IAN
consecutive 80 readings within 15 minutes, and
the 80 reading was sustained continuously for 60
block1,13 using a 27-gauge 114-inch Luer-Lok
needle (Becton, Dickinson, Franklin Lakes, N.J.)
minutes (that is, for most restorative procedures,
attached to a 5-mL Luer-Lok syringe (Becton,
we would want the patient to experience numbDickinson). We used the Luer-Lok syringe
ness within 15 minutes and to remain numb for
because we wanted to administer 0.4 mL of the
60 minutes).
lidocaine solution as we advanced the needle
Statistical analysis. With a nondirectional
toward the target area to decrease the pain of
risk of .05 and a power of 80 percent, a sample
needle placement. If we had used a standard
size of 51 subjects was required to demonstrate a
dental syringe and administered 0.4 mL as the
difference of 25 percent in anesthetic success.
R E S E A R C H
TABLE 1
100
80
60
40
20
Bevel Toward Mandibular Ramus
PERCENTAGE OF 80 READINGS
100
80
60
40
20
Bevel Away From Mandibular Ramus

0
1
17
25
33
41
49
57
17
Figure 1. Incidence of first molar anesthesia as determined by the

lack of response to electrical pulp testing at the maximum setting
(80 readings) at each postinjection interval for the two needle bevel
orientations.
1688
JADA, Vol. 137
25
33
41
49
57
TIME (MINUTES)
TIME (MINUTES)
Figure 2. Incidence of second premolar anesthesia as determined

by the lack of response to electrical pulp testing at the maximum
setting (80 readings) at each postinjection interval for the two
needle bevel orientations.

needle bevel oriented

toward the mandibular
Subjects who experienced anesthetic success.
ramus, did not result in
TOOTH IN WHICH
NUMBER (%) OF SUBJECTS
P VALUE*
profound lip numbness at
ANESTHETIC SUCCESS
WAS ACHIEVED
15 minutes (and were conNeedle Bevel
Needle Bevel
Oriented Away
Oriented Toward
sidered unsuccessful
From Mandibular
Mandibular Ramus
blocks). We scheduled these
Ramus (n = 51)
(n = 51)
patients for subsequent
46 (90)
47 (92)
1.000
Second Molar
appointments. Eventually,
39 (76)
37 (73)
.727
First Molar
all 51 subjects experienced
profound lip anesthesia
40 (78)
40 (78)
1.000
Second Premolar
with both needle bevel
41 (80)
37 (73)
.344
First Premolar
orientations.
22 (43)
17 (33)
.227
Lateral Incisor
Table 1 shows the rates
of anesthetic success. For
12 (24)
7 (14)
.227
Central Incisor
the needle bevel oriented
* There were no significant differences (P > .05) between the two needle bevel orientations.
away from the mandibular
ramus, successful pulpal
The research assistant recorded the time of anesanesthesia ranged from 24 to 90 percent from the
thesia onset as the first of two consecutive 80
central incisor to the second molar. With the
readings.
needle bevel oriented toward the mandibular
We used exact McNemar tests to analyze comramus, successful pulpal anesthesia ranged from
14 to 92 percent. The results showed no signifiparisons between the bevel orientation (that is,
cant difference between the two needle bevel oriaway or toward the mandibular ramus) nonparaentations for any tooth. Figures 1 through 4 show
metrically for anesthetic success. We used the
the incidence of pulpal anesthesia (80 readings)
Wilcoxon signed ranks, matched pairs test to comfor the two injection techniques for representative
pare the onset of anesthesia between the two
teeth.
techniques. We considered comparisons to be
The mean onset times of pulpal anesthesia
significant at P < .05.
for subjects who achieved pulpal anesthesia
RESULTS
(that is, two consecutive 80 readings) are presented in Table 2. The results show no signifiA total of 22 IAN blocks, 11 administered with
cant difference between the two needle bevel
the needle bevel oriented away from the
orientations.
mandibular ramus and 11 administered with the
R E S E A R C H
100
80
60
40
20

100
17
25
33
41
49
80
60
40
20
0
1
17
25
33
41
49
57
57
TIME (MINUTES)
TIME (MINUTES)
Figure 4. Incidence of central incisor anesthesia as determined by

the lack of response to electrical pulp testing at the maximum setting (80 readings) at each postinjection interval for the two needle
bevel orientations.
DISCUSSION
that anesthetic success was not significantly different when needle bevels were oriented away or
toward the mandibular ramus when using a 27gauge needle. Therefore, we do not think it is necessary to use commercial 27-gauge needles with
markers indicating the needle bevel. For the most
part, the results of our study were similar to the
rates of anesthetic success and incidence of pulpal
anesthesia reported in other studies of the IAN
block.1 Neither of the needle bevel orientations
provided complete pulpal anesthesia for
mandibular teeth (Table 1) (Figures 1 through 4),
which could present meaningful clinical problems
because the teeth might not be numb enough for
procedures requiring complete pulpal anesthesia.
We based our use of the pulp test reading of

80signaling maximum outputas a criterion
for pulpal anesthesia on the studies of Dreven
and colleagues14 and Certosimo and Archer.15
These studies14,15 showed that when patients did
not respond to an 80 reading, this ensured pulpal
anesthesia in vital asymptomatic teeth. In addition, Certosimo and Archer15 demonstrated that
electric pulp test readings of less than 80 resulted
in pain during operative procedures in asymptomatic teeth. Therefore, using the electric pulp
tester before beginning dental procedures on
asymptomatic vital teeth will provide the clinician with a reliable indicator of pulpal anesthesia.
TABLE 2
Because all subjects
reported that they felt proAnesthesia onset times.*
found lip numbness,
TOOTH IN WHICH
MEAN ONSET TIME IN MINUTES
ANESTHETIC SUCCESS
( STANDARD DEVIATION)
despite pulp testing that
WAS ACHIEVED
Needle Bevel
Needle Bevel
revealed that subjects did
Oriented Away
Oriented Toward
not always achieve pulpal
From Mandibular
Mandibular
Ramus
Ramus
anesthesia (a reading of
80), asking the patient if
5.3 ( 5.6)
3.9 ( 4.7)
Second Molar (n = 49)
his or her lip is numb indi8.8 ( 7.8)
9.2 ( 8.5)
First Molar (n = 43)
cates only whether soft10.2 ( 11.5))
10.3 ( 10.0)
Second Premolar (n = 47)
tissue anesthesia has been
achieved, but does not
11.1 ( 10.0)
10.8 ( 9.7)
First Premolar (n = 48)
guarantee that pulpal
17.1 ( 17.6)
13.0 ( 13.9)
Lateral Incisor (n = 23)
anesthesia has been
19.1 ( 11.1)
19.4 ( 14.0)
Central Incisor (n = 11)
achieved.
Anesthetic success.
* For subjects who achieved pulpal anesthesia.
There were no significant differences (P > .05) between the two needle bevel orientations.
Our study results show
P VALUE
December 2006
.135
.526
.403
.898
.681
.930
1689
Figure 3. Incidence of lateral incisor anesthesia as determined by

the lack of response to electrical pulp testing at the maximum setting (80 readings) at each postinjection interval for the two needle
bevel orientations.
R E S E A R C H
1690
JADA, Vol. 137
needle into the pterygomandibular space as close

to the IAN as possible so that the local anesthetic
solution is deposited in close proximity to the
nerve. Berns and Sadove,20 using radiopaque dyes
and radiographs of needle placement, found that
even with accurate needle placement, 25 percent
of IAN blocks resulted in inadequate anesthesia.
Using a medical ultrasonographic technique for
needle placement for IAN blocks, Hannan and colleagues21 concluded that accurate needle placement did not result in more successful pulpal
anesthesia. Galbreath22 reported that the course
of anesthetic solution migration could not be predicted accurately; it was determined by the path
of least resistance and by the fascial planes and
structures encountered in the pterygomandibular
space. The migration of anesthetic solution might
help explain why accurate needle placement, or
needle bevel orientation, may not result in pulpal
anesthesia.
Both of the needle orientations in our study
resulted in the same number of unsuccessful IAN
blocks (that is, a lack of lip numbness within 15
minutes). Therefore, needle bevel orientation does
not seem to affect the number of unsuccessful
blocks. However, waiting 15 minutes before
beginning the dental procedure might not guarantee adequate pulpal anesthesia.1 Using an electric pulp tester before dental procedures provides
the clinician with a reliable indicator of pulpal
anesthesia onset.
We found no significant differences in mean
anesthesia onset times (Table 2). Therefore,
needle bevel orientation does not seem to affect
the time of onset of pulpal anesthesia. We did not
measure the duration of pulpal anesthesia in our
study because we ended testing at 60 minutes.
Figures 1 through 4 show that pulpal anesthesia
of at least 60 minutes duration after an IAN
block is likely to occur in subjects in whom pulpal
anesthesia is achieved.
CONCLUSION
The results of this study show that using a 27gauge needle with the bevel oriented away from
the mandibular ramus was similar to using a 27gauge needle with the bevel oriented toward the
mandibular ramus with regard to achieving
pulpal anesthesia after administration of IAN
blocks in adults. I
1. Nusstein J, Reader A, Beck M. Anesthetic efficacy of different volumes of lidocaine with epinephrine for inferior alveolar nerve blocks.
Gen Dent 2002;50(4):372-5.

Practitioners should consider supplemental techniques, such as intraosseous3,4,16-18 or periodontal

ligament injections,2 when an IAN block fails to
achieve pulpal anesthesia for a particular tooth.
Because we studied a young adult population, the
results of this study might not apply to children
or elderly patients.
Needle gauge. While Aldous10 reported that
less deflection occurred with larger-gauge needles, Cooley and Robison7 found that the amount
of deflection with 27- and 30-gauge needles was
nearly identical. Robison and colleagues11 studied
the deflection characteristics of 25-, 27- and 30gauge needles and found that the majority of needles exhibited no statistical differences in the
amount of deflection. Hochman and Friedman9
observed that 25-gauge needles deflected less
than did 27-and 30-gauge needles in hydrocolloid
and frankfurters. However, in wax, the 27-gauge
needle deflected more than did the 30- and 25gauge needles.9 Therefore, as these studies found,
all needles deflect away from the bevel and the
amount of deflection in relation to needle gauge
seems to depend on the study. We selected the 27gauge needle for our study because Malamed19
stated that one of the most commonly used (that
is, most purchased) needles in dentistry is the 27gauge needle. Future studies might address the
association between different needle gauges and
anesthetic success.
The 27-gauge needle used in the study was
approximately 32 mm long with an ultrasharp,
tribeveled needle tip. In comparing 20 sample
needles under the dental microscope, we found
that a standard Monoject (Kendall, Mansfield,
Mass.) 27-gauge dental needle was identical to
the needle we used in length and bevel characteristics. The only difference was that the Monoject
dental needle passed through the hub to allow
cartridge penetration, while the Becton Dickinson
needle hub screws onto the disposable Luer-Lok
syringe. Use of the Luer-Lok syringe allowed
aspiration and delivery of the anesthetic solution
in a manner similar to that of a dental aspirating
syringe.
With regard to the pattern of fluid flow and the
needle bevel, Cooley and Robison7 found that fluid
was deposited on each side of the bevel, and the
direction of the bevel did not appear to affect the
pattern of fluid in the tissues. Future studies
might address the pattern of fluid flow with different needle gauges.
The objective of the IAN block is to direct the
R E S E A R C H
flecting dental needles in vitro. Anesth Prog 1985;32(2):62-4.

13. Jorgensen NB, Hayden J Jr. Local and general anesthesia in dentistry. 2nd ed. Philadelphia: Lea & Febiger; 1967:69-70.
14. Dreven LJ, Reader A, Beck M, Meyers WJ, Weaver J. An evaluation of an electric pulp tester as a measure of analgesia in human
vital teeth. J Endod 1987;13(5):233-8.
15. Certosimo AJ, Archer RD. A clinical evaluation of the electric
pulp tester as an indicator of local anesthesia. Oper Dent
1996;21(1):25-30.
16. Parente SA, Anderson RW, Herman WW, Kimbrough WF, Weller
RN. Anesthetic efficacy of the supplemental intraosseous injection for
teeth with irreversible pulpitis. J Endod 1998;24(12):826-8.
17. Nusstein J, Kennedy S, Reader A, Beck M, Weaver J. Anesthetic
efficacy of the supplemental X-tip intraosseous injection in patients
with irreversible pulpitis. J Endod 2003;29(11):724-8.
18. Prohic S, Sulejmanagic H, Secic S. The efficacy of supplemental
intraosseous anesthesia after insufficient mandibular block. Bosn J
Basic Med Sci 2005;5(1):57-60.
19. Malamed SF. Handbook of local anesthesia. 5th ed. St. Louis:
Mosby; 2004:101.
20. Berns JM, Sadove MS. Mandibular block injection: a method of
study using an injected radiopaque material. JADA 1962;65:735-45.
21. Hannan L, Reader A, Nist R, Beck M, Meyers WJ. The use of
ultrasound for guiding needle placement for inferior alveolar nerve
blocks. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
1999;87(6):658-65.
22. Galbreath JC. Tracing the course of the mandibular block injection. Oral Surg Oral Med Oral Pathol 1970;30(4):571-82.

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2. Cohen HP, Cha BY, Spangberg LS. Endodontic anesthesia in

mandibular molars: a clinical study. J Endod 1993;19(7):370-3.
3. Reisman D, Reader A, Nist R, Beck M, Weaver J. Anesthetic efficacy of the supplemental intraosseous injection of 3 percent mepivacaine in irreversible pulpitis. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 1997;84(6):676-82.
4. Nusstein J, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of the supplemental intraosseous injection of 2 percent lidocaine
with 1:100,000 epinephrine in irreversible pulpitis. J Endod
1998;24(7):487-91.
5. Kennedy S, Reader A, Nusstein J, Beck M, Weaver J. The significance of needle deflection in success of the inferior alveolar nerve block
in patients with irreversible pulpitis. J Endod 2003;29(10):630-3.
6. Claffey E, Reader A, Nusstein J, Beck M, Weaver J. Anesthetic
efficacy of articaine for inferior alveolar nerve blocks in patients with
irreversible pulpitis. J Endod 2004;30(8):568-71.
7. Cooley R, Robison SE. Comparative evaluation of the 30-gauge
dental needle. Oral Surg Oral Med Oral Pathol 1979;48(5):400-4.
8. Davidson MJ. Bevel-oriented mandibular injections: needle deflection can be beneficial. Gen Dent 1989;37(5):410-2.
9. Hochman MN, Friedman MJ. In vitro study of needle deflection: a
linear insertion technique versus a bidirectional rotation insertion
technique. Quintessence Int 2000;31(1):33-9.
10. Aldous JA. Needle deflection: a factor in the administration of
local anesthetics. JADA 1968;77(3):602-4.
11. Robison SF, Mayhew RB, Cowan RD, Hawley RJ. Comparative
study of deflection characteristics and fragility of 25-, 27-, and 30gauge short dental needles. JADA 1984;109(6):920-4.
12. Jeske AH, Boshart BF. Deflection of conventional versus nonde-

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