a supernumerary tooth is the one that is additional to the normal series and can be found in almost any region of the dental arch . their reported prevalence ranges between 0.3 - 0.8% in the primary dentition and 0.1 - 3.8% in the permanent dentition . supernumerary teeth can present as one or many , unilaterally or bilaterally and in either of the jaws . in contrast , cases involving multiple supernumerary teeth tend to involve the mandibular premolar region . in study of non - syndrome multiple supernumerary teeth , yusof found 60.9% of the total sample to occur in the mandible and 44.8% in the mandibular premolar region . the etiology of supernumerary teethis not completely understood but both genetic and environmental factors have been implicated in the phenomenon . several theories have been suggested to explain their occurrence such as atavism , dichotomy theory , dental lamina hyperactivity theory . supernumerary teeth can be classified based upon morphology ( conical , tuberculate , supplemental , odontomes ) or location ( mesiodens , paramolar , distomolar , parapremolar ) . supernumerary teeth may have several fates like normal eruption , remain impacted , appear inverted or erupt in an abnormal path . literature shows that only ( 13 - 34)% of all permanent supernumerary teeth are erupted , compared with 73% of primary supernumerary teeth . a supernumerary tooth does not always necessarily produce complications and can be accidentally diagnosed in routine radiographic examinations . but if symptomatic , can present with various clinical manifestations such as displacement , rotation or obstruction to eruption of associated tooth , crowding , root resorption of adjacent teeth , incomplete space closure during orthodontic treatment and pathologies associated with the supernumerary tooth itself . several developmental disorders frequently show association with multiple supernumerary teeth . these include cleft lip and palate , cleidocranialdysostosis , gardner 's syndrome and less frequently fabry anderson 's syndrome , ehlers - danlos syndrome , incontinentia pigmenti and trico - rhino - phalangeal syndrome . alarming signs that should alert a clinician to the possible presence of supernumerary teeth include unilateral persistence of a deciduous tooth , failure of eruption or ectopic eruption of a permanent tooth , a wide midline diastema or interdental spacing , or rotation of erupted permanent tooth . the most useful radiographic investigation in diagnosis of supernumerary teeth is the orthopantomogram ( opg ) , with additional views of the anterior maxilla and mandible in the form of occlusal or periapical radiographs . presently , conebeam computed tomography ( cbct ) is being effectively used to evaluate supernumerary teeth . this technique yields detailed three dimensional images of local structures and may prove useful in pre - treatment evaluation of supernumerary teeth and surrounding structures . decision on how to manage supernumeraries depends on the type and position of the supernumerary tooth and on its effect or potential effect on adjacent teeth . a 14 year old girl reported to the department of oral and maxillofacial surgery of school of stomatology , jiamusi university ( china ) with a chief complaint of delayed eruption of upper and lower front permanent teeth and unaesthetic appearance . on intra - oral examination , deciduous teeth in various stages of exfoliation and permanent teeth in various stages of eruption were seen , but both the processes not occurring in a normal chronological order . 51 and 61 were still retained and appeared larger than usual with v - shaped notching of the incisal edge . the absence of 52 and 62 , and negative history of extraction or exfoliation of the same raised a suspicion towards fusion of 51 , 52 and 61 , 62 ; but that could still be a structural abnormality of the central incisors with absence of laterals . 53 , 54 , 55 , 63 , 64 , 65 , 72 , 73 , 74 , 83 , 84 and 85 were also still retained . the only permanent teeth clinically visible were 16 , 26 , 31 and only the incisal edge of 41 . this bizarre state of teeth eruption and exfoliation warranted a radiographic examination and an orthopantomogram ( opg ) was advised to see the status of underlying dentition [ figure 1 ] . preoperative orthopantomogram of the patient with markings of supernumerary teeth ( in red ) and permanent teeth of normal series ( in black ) the opg showed various impacted permanent teeth of normal series and many supernumerary teeth in all quadrants . as per the opg , fifteen supplemental teeth could be rule out in total ; eight in maxilla and seven in mandible . a cbct of mandibular and maxillary dentition was again advised to rule out any missing supernumerary teeth in the opg . consequently , the cbct revealed four additional supernumerary teeth in the patients ( one in mandible and three in maxilla ) that were missed in the opg due to overlapping of the osseous and dental structures [ figures 24 ] . the presence of multiple retained deciduous , unerupted permanent and supernumerary teeth raised suspicion of any associated syndromic disorders but a detailed consultation with pediatrician , pedodontist and general physician ruled out the presence of any craniofacial syndromes or systemic disorders in the patient . thus , a diagnosis of  non - syndromic multiple supernumerary teeth  was made . it was not very easy to differentiate some permanent teeth of normal series from the supernumeraries , and thus an assumption that these extra teeth should be supplemental was made . on the other hand , some supernumeraries were in early stages of development or poorly developed , so proper anatomy could not be studied . cone - beam computed tomography revealing additional supernumerary tooth in left mandibular quadrant cone - beam computed tomography revealing additional supernumerary tooth in left maxillary quadrant cone - beam computed tomography revealing additional two supernumerary teeth in right maxillary quadrant the association of various permanent teeth with the supernumerary teeth is demonstrated through a schematic diagram [ figure 5 ] . after consultation with orthodontist and pedodontist , a treatment plan was made to extract all the supernumeraries and retained deciduous teeth carefully with as much minimal trauma as possible to the permanent teeth of normal series . this would be followed by comprehensive orthodontic treatment that includes careful monitoring of the eruption status , space maintenance , surgical exposure and orthodontic traction of teeth as required . presence of supernumerary tooth in normal dentition is not an unusual phenomenon but the presence of multiple supernumerary teeth in individuals without any syndromic disorder is not common . the most common location for a single supernumerary has been cited as anterior maxilla , specifically the midline . in contrast , multiple supernumerary teeth has been found to occur more frequently in the premolar region . ansari et al . in 2013 reported a case of thirteen supplemental teeth in non - syndromic patient and before this case was presented , that was probably the highest number of supernumerary teeth reported in a single non - syndromic patient . all of the supernumerary teeth in that patient occurred in the premolar region in contrast , in the present case , among the nineteen supernumerary teeth , one was present in maxillary midline region ( mesiodens ) , one each was associated with 11 , 13 , 21 , 23 , 32 , 33 , 34 , 35 . three supernumeraries were associated with 14 and 15 , three with 25 , two with 44 and two with 45 . this accounts to 58% of the total supernumerary teeth in maxilla and 42% in the mandible among which 37% were present in anterior region and 63% in premolars region . this is in contrast to data in a landmark review on the subject matter by yusof who reported an incidence of 60.09% in mandible and 44.8% in mandibular premolars . cortes - breton brinkmann et al . in 2013 published an extensive review of non - syndromic multiple supernumerary teeth in which they reviewed 13 patients with total of 55 supernumerary teeth . they defined multiple as the presence of three or more supernumerary teeth in a single patient , taking in consideration the fact that cases of three or more non - syndromic supernumerary teeth constituted less than 1% of published literature and that a number of authors have followed the same criteria . this is in contrast to yusof , who considered five or more than five teeth as the criteria . in the review by cortes - breton brinkmann and workers , they presented the incidence to be 50.9% in mandible and 49.1% in maxilla , which is again in contrast to data of our case . they showed that 69.1% of the supernumerary teeth had a supplemental morphology and 30.9% were heteromorphic . in our case , 16 teeth ( 84.2% ) had a supplemental morphology and 3 teeth ( 15.8% ) were heteromorphic . furthermore , they mentioned in their review that 94.5% of the supernumerary teeth were impacted , whereas in our patient , all the supernumerary teeth were impacted . they also reported that 43.6% of the teeth had an associated disease but we did not find such findings in our case . orthopantomogram has been the modality of choice for investigating the status of supernumerary teeth , but the introduction of cone beam computed tomography ( cbct ) to radiographic technology has proved as the most effective three dimensional means of examining dental and associated osseous structures . in our case too , four additional supernumerary teeth could be located in cbct only which was easily missed in the opg due to overlapping of dental and osseous structures . thus , cbct can be regarded as the best choice for investigating multiple supernumerary teeth . regarding management issues of supernumerary teeth , established guidelines do not exist but few things need to be considered . if the teeth are asymptomatic with no radiographic evidences of any pathologies and not likely to interfere with orthodontic tooth movement , ( location beyond teeth apices ) they can be monitored with periodic radiographic examination . but if the patient does not want to risk any complications , considerations can be given to extraction . if associated with roots of permanent teeth , waiting till the completion of root development should be considered to minimize the chances of root damage . but if the supernumerary teeth are associated with any sort of complications like cysts or tumors , obstruction to normal teeth eruption , hindrance to orthodontic tooth movement and unaesthetic appearance , extraction is a logical management in those cases . in the case reported , the sole reason for extraction was obstruction to normal teeth eruption and thus retention of deciduous dentition . though the post - extraction phases are not presented in the report , the patient was referred to orthodontics department for monitoring of eruption , space management and necessary orthodontic procedures to guide the teeth into normal occlusion . the clinician should be familiar with the early clinical manifestations of the presence of supernumerary tooth / teeth in the dentition so that necessary early intervention could be taken to prevent any possible complications . moreover , presence of multiple supernumerary teeth should always raise suspicion to presence of any craniofacial syndromes or systemic disorders . after diagnosis and treatment , a periodic long term observation of the dentition is paramount to favorable results .
supernumerary teeth occur frequently in human dentition , but presence of multiple supernumerary teeth in patients without any associated syndrome or systemic disorder is a rare phenomenon . 
 presence of supernumerary teeth in itself is not a problem and may not require removal in all cases but in certain conditions , they may be associated with several clinical complications and require removal . here , we present a 14 year old female who complained of non emergence of permanent teeth . 
 orthopantomogram initially showed presence of fifteen impacted supernumerary teeth distributed in all quadrants , but later , cone - beam computed tomography further revealed four additional teeth , totaling to nineteen supernumerary teeth . 
 consultation with concerned specialists ruled out any syndromes or systemic disorders which led us to the diagnosis of  non - syndromic multiple supernumerary teeth  and 
 this probably is the highest number of supernumerary teeth reported in a single non - syndromic patient till date .