Purpose: This case study describes decision-making where a permanent tooth is inadvertently extracted in a child with complex congenital cardiac disease (CCCD). Methods: The clinical situation, decision-making, expected outcome and follow-up are described. Case report: A 3-year-old child with a background of hypoplastic right ventricle presented with severe early childhood caries. This necessitated comprehensive treatment under general anaesthetic (GA) to prepare him for further surgery. In the pre-operative radiographs, a clearly defined but apparently hypoplastic dental follicle of tooth 45 was seen in the furcation of the roots of tooth 85. This localised hypoplasia was assumed to be related to the gross infection of tooth 85. When 85 was extracted, the follicle of 45 was attached to its roots in the furcation. Results: The decision not to replant the bud was made because: a) the site for reimplantation was chronically infected, giving a poor prognosis for replantation and increasing the child's risk of infective endocarditis; b) aspiration risk secondary to early loss post-GA was a concern; c) detaching the follicle from the primary molars roots to replant it could have further damaged the bud; d) the child's young age and poor cooperation would make appropriate surveillance impossible; and d) the event of failure would entail a likely repeat GA. The child's mother was informed about the event. Favourable mesial drift of the permanent first molar is to be expected. The tissue was sent to histopathology to confirm the clinical findings. Summary: Although the loss of a permanent successor during extraction of a primary tooth is unfortunate, the child's overall health is the overriding factor in decision-making. Conclusion: Maintaining a healthy mouth is important in CCCD. This case demonstrates the complexity of treatment planning for children with CCCD and further highlights the importance of well-maintained oral health from an early age. Keywords: complex congenital cardiac disease, inadvertently extracted, successor follicle attached to infected primary tooth