It is well understood that unsupported finger movements in extension or flexion are relatively unstable and not suited for endodontic microsurgery [10, 12]. Therefore, wrist stabilization on a fixed surface with a 20° angulation in dorsiflexion decreases muscle tremor and mitigates unsupported finger flexion and extension thereby providing finely controlled finger movements [10, 12].

Physiologic hand tremor is not unusual and a manifestation of intentional and unintentional actions causing hand and finger movement [13]. The realization of a surgeon’s tremor becomes more obvious with visual enhancement of magnification. It typically is associated with tension generated by poor postural control, unsupported hand, and unstable instrument holding position, but several other factors have been associated with hand tremor such as cigarette smoking, alcohol withdrawal, caffeine, hypoglycemia, hyperparathyroidism, pheochromocytoma, and Wilson’s disease. Drug-induced hand tremor is a nervous system and muscle response to certain medications which include valproic acid, albuterol, cyclosporine, lithium carbonate, tricyclic antidepressants, antivirals such as acyclovir, and certain blood pressure drugs [14]. To perform endodontic surgery with microsurgical techniques and to minimize hand tremors, the surgeon must be in a relaxed and proper mind-set. To perform highly esthetic results, the endodontic surgeon must consider his/her attitude with mental focus and patience in order to maintain precise motor skills [10, 11].

It is interesting to consider that with the rapid expansion and utilization of technological advances of computers and even text messaging on handheld mobile devices, there is very little emphasis on handwriting or penmanship. In an academic setting or for the contemporary specialist dentist trainee, this lack of emphasis provides little background for good ergonomic habits during training [11, 15].

The three-digit pen or internal precision grip is the most commonly utilized in microsurgery and provides excellent stability particularly when compared to other hand grips [9, 16]. As its name suggests this grip mimics a three-digit pen grip with the thumb, index finger, and middle finger creating an effective tripod [9]. The surgeon’s hand should rest on an immovable flat surface with support of the ulnar surface of the wrist and forearm. With this tripod in place, the instrument is supported by the middle finger with the thumb and index finger placed in contact with the instrument. Opening and closing of an instrument requires very fine movements, and any possible tremor is minimized. By utilizing the pen or internal precision grip, the flexor and extensor muscles of the hand remain relaxed facilitating accurate movement. Finally, proper surgical ergonomics not only helps prevent back and neck problems; it provides the functional environment to properly perform endodontic microsurgery and prevent esthetic complications. The patient and chair position should be adjusted to the surgeon and microscope with the surgeon seated in an upright position with thighs approximately at a right angle to the knees [17].

Microsurgical instrumentation, accurate hand movement with precision hand grip, and correct posture and position of the endodontic surgeon (Fig. 7.4) are critical factors in avoiding esthetic complications.