UNLABELLED: Type II odontoid fractures are the most common cervical injury in geriatric populations, yet optimal management remains debated. This study compared the safety and effectiveness of non-surgical management (NSM), anterior dens screw (ADS) fixation, and posterior arthrodesis (PA) in these patients. A systematic review and frequentist network meta-analysis was conducted according to PRISMA-NMA guidelines. PubMed/MEDLINE, Embase, and CENTRAL were searched from inception to October 2025. Comparative studies including patients ≥ 60 years with Anderson-D’Alonzo type II fractures and reporting at least one primary outcome (mortality, union, stable non-union, unstable non-union) were eligible. Random-effects network models generated pooled odds ratios (ORs) with 95% confidence intervals (CIs). Nineteen studies involving 1242 patients were included (475 NSM; 340 ADS; 427 PA). Mortality did not differ among strategies. PA demonstrated the highest odds of union (OR 8.35, 95% CI 3.79–18.40 versus NSM), followed by ADS (OR 2.19, 95% CI 1.10–4.35 versus NSM). PA also outperformed ADS for fusion (OR 0.26, 95% CI 0.12–0.56). Stable non-union odds were similar across interventions, but unstable non-union was significantly more common after NSM (ADS versus NSM OR 5.93, 95% CI 1.33–26.35; PA versus NSM OR 13.55, 95% CI 2.50–73.36). Systemic morbidity was higher after both ADS (OR 1.87, 95% CI 1.02–3.44) and PA (OR 2.29, 95% CI 1.20–4.36) compared with NSM, while mechanical complications and secondary operation were uncommon and comparable. No global or local inconsistency was detected. In geriatric patients with type II odontoid fractures, PA provides the most reliable fusion and lowest unstable non-union risk, whereas NSM offers comparable survival with lower systemic morbidity but higher structural failure. ADS occupies an intermediate position, benefiting select anatomies where motion preservation or avoidance of prone surgical positioning is advantageous. Treatment should be individualized using a morphology-frailty framework that balances biomechanical stability against physiological reserve. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s10143-026-04170-8.