Background <p>Restorative options, including crowns, have evolved from traditional extractions to a focus on preserving primary teeth for aesthetic and functional benefits. Materials like bis-acryl composite-based temporization offer cost-effective, reliable solutions for temporary restorations, with custom-made composite shell crowns providing accurate, aesthetic outcomes, reducing chairside time and improving overall treatment success.This study aimed to clinically compare temporization crowns and composite shell crowns for anterior rehabilitation in primary teeth, using the modified USPHS/Ryge criteria and evaluating crown survival.</p> Methods <p>A total of 90 carious primary maxillary incisors from healthy children (19 females and 14 males), aged between 4 and 7 years, were included and divided into two groups. Group 1 received strip crowns made with temporization material, while Group 2 received composite shell crowns. Crowns were evaluated at 3, 6, and 9 months using the Modified USPHS/Ryge criteria, assessing marginal discoloration, marginal integrity, surface texture, wear, postoperative sensitivity, and recurrent caries.</p> Results <p>At baseline, no failures were reported in either group. By 3 months, intervention was needed in two cases ingroup 1 and one in group 2, with further material loss in two cases in group 1 and one ingroup 2 by 9 months. The final analysis included 41 participants in group 1 and 37 in group 2. At 9 months, group 2 (composite shell crowns) outperformed group 1 (strip crowns with temporization material) in all parameters. At the 9-month evaluation, TSCs showed higher rates of superficial (24.4%) and deep staining (4.9%) compared to CSCs (2.7% each). TSCs also had more issues with marginal integrity (14.6% with visible crevices) and surface texture (14.6% rough, 4.9% very rough) than CSCs (2.7% for each). Wear was observed in the TSC group (4.9% without dentin exposure, 2.4% with exposure), while the CSC group showed no wear. No postoperative sensitivity and secondary caries was reported in either group.</p> Conclusion <p>Composite shell crowns demonstrated superior esthetics, marginal integrity, and longevity compared to strip crowns with temporization material. Their reduced discoloration and better durability make them a preferable choice for anterior primary teeth rehabilitation in pediatric dentistry.</p> Trial registration <p>CTRI/2024/11/077290 (retrospectively registered). This trial was registered on 2024-11-25.</p>