An actuation mechanism for a medical instrument includes a pinion and a face gear that move a push-pull element. The pinion has a mounting that permits rotation of the pinion by an external control system such as a robot. The face gear meshes with the pinion. The push-pull element may have a proximal end coupled to the face gear and a distal end coupled to a tool at a distal end of an instrument shaft. A manipulator coupled for manual rotation of the actuation mechanism may include a slip clutch to prevent manual application of excessive force to the actuation mechanism.